CMS remote patient monitoring reimbursement and telehealth reimbursement can be difficult subjects to navigate, especially during the COVID-19 PHE. Luckily, our reimbursement team has put together a FAQ to simplify things!
Our reimbursement team answers the questions below.
Common RPM Reimbursement Questions
Q: What are the RPM CPT Codes from CMS?
A: The five primary Medicare RPM codes are CPT codes 99091, 99453, 99454, 99457, and 99458. Additionally, CMS proposed five new CPT codes for Remote Therapeutic Monitoring (RTM). While different from RPM, the RTM codes will expand access to telehealth.
Q: What do the 5 RPM codes cover? Are there documentation requirements?
A: The standard codes for Remote Patient Monitoring (RPM) are 99453, 99454, 99457 and 99458. These codes are for RPM services and were available prior to the COVID-19 outbreak. CPT Code 99453 is for the initial set-up, 99454 is the supply of the device, collection, transmission and report/summary services to the clinician. CPT Codes 99457 and 99458 are the remote physiologic monitoring services by clinical staff/MD/QHCP.
These codes require general supervision by an MD or NP. The codes are for Part B services and are billed on a 1500 form using the NPI number of supervising QHCP either an MD or NP. NP’s also have the opportunity to bill E&M codes 99201 to 99215.
Q: Are there patient co-pays for the RPM codes?
A: Normally, there are. Like all medicare services, patients are responsible for applicable co-pays depending on the service rendered. That being said, during the COVID PHE, providers can waive copays for RPM.
Q: Are the RPM codes only available for patients with chronic conditions?
A: No, the codes are not limited to just chronic conditions.
Q: Can RPM be used with new and established patients?
A: Yes, during the PHE. Let’s dive into this a bit more—in CMS’ 2021 Final RUle, they stated RPM services are limited to “established patients.” At the beginning of COVID-19, CMS waived the “established patient” requirement—CMS stated that practitioners may provide RPM services without first conducting a new patient E/M service. In the 2021 Final Rule, CMS declined to extend the waiver beyond the PHE, meaning, an established patient-practitioner relationship will be required to bill Medicare for CPT 99452, 99454, 99457, and 99458.
Q: Can Telehealth visits be made for palliative care consult visits by NPs and what codes should be used?
A: Yes, palliative care consult visits can be performed by NPs through telehealth. With the waivers in place by CMS for Telehealth services there are no restrictions for where the patient is located or rural indicator, the NP can bill E&M codes 99201-99215 or the RPM codes of 99453, 99454, 99457 and 99458.
Q: Does the ability to do remote visits, when clinically appropriate, apply to all disciplines (nursing and rehab)?
A: The ability to do remote visits when clinically appropriate does apply to all disciplines during the pandemic of COVID-19. However keep in mind that not all remote visits will be reimbursable depending on the setting and discipline among other factors.
Q: What constitutes an RPM device?
A: The device must meet the FDA’s definition of a medical device as described in section 201(h) of the Federal, Food, Drug and Cosmetic Act. The device must digitally, i.e, automatically, upload patient physiologic data.
Q: Can you define “clinical staff” in the context of RPM reimbursement?
A: Per CMS and the CPT codebook, a clinical staff member is defined as “a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service but does not individually report that professional service.”
Have additional questions or comments? Please contact our reimbursement team at firstname.lastname@example.org