CMS remote patient monitoring reimbursement and telehealth reimbursement can be difficult subjects to navigate. Luckily, our reimbursement team has put together a FAQ to simplify things!

Let's review the commonly asked questions and answers around RPM reimbursement.

Common Remote Patient Monitoring Reimbursement Questions

1. What are the RPM CPT Codes from CMS?

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. 

2. What do the 5 RPM codes cover? Are there documentation requirements? 

The standard codes for Remote Patient Monitoring (RPM) are 99453, 99454, 99457 and 99458. These codes are for RPM services. 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. NPs also have the opportunity to bill E&M codes 99202 to 99215.

3. Are there patient co-pays for the RPM codes?

Yes, there are. Like all Medicare services, patients are responsible for applicable coinsurance depending on the service rendered.

4. Are the RPM codes only available for patients with chronic conditions?

No, the codes are not limited to just chronic conditions

5. Can RPM be used with new and established patients?

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.

6. Can telehealth visits be made for palliative care consult visits by NPs and what codes should be used?

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 99202-99215 or the RPM codes of 99453, 99454, 99457 and 99458.

7. Does the ability to do remote visits, when clinically appropriate, apply to all disciplines (nursing and rehab)?

The ability to do remote visits when clinically appropriate does apply to all disciplines. However keep in mind that not all remote visits will be reimbursable depending on the setting and discipline among other factors.

8. What constitutes an RPM device?

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. 

9. Can you define “clinical staff” in the context of RPM reimbursement?

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.”

Unpacking the Various Remote Patient Monitoring Reimbursement Models 

When it comes to RPM reimbursement, there are multiple options and CMS is not the only possible source of reimbursement. In this section, we respond to some of the commonly asked questions around different reimbursement models. 

1. Why choose CMS for telehealth and remote patient monitoring reimbursement? 

CMS covers a wide range of telehealth and RPM services. Being a CMS billable provider to obtain reimbursement through CMS opens up a large population of patients who can benefit from telehealth and RPM services, which helps organizations increase their revenue stream.  

2. Why would patients choose a private pay model instead? 

Patients that have come to rely on the daily oversight, equipment, and care provided by their telehealth clinicians often appreciate a flexible private pay option. Besides preserving strong patient-clinician relationships that lead to increased patient satisfaction, private pay models can also create revenue streams and greater returns for telehealth care providers.  

The high level of clinician post-care involvement also proactively lowers the risk of repeat hospitalization events and ED visits. It also goes without saying that telehealth providers that offer flexible private pay options stand out from the competition.  

3. What are MCOs and ACOs? Why are they viable RPM reimbursement options? 

Managed Care Organizations (MCOs) and Accountable Care Organizations are healthcare providers that group and coordinate to provide affordable but high-quality care to patients. The benefits of joining either is twofold: besides obtaining centralized medical records and patient histories that help the coordination of care between medical teams, Medicare also incentivizes care organizations to reduce care costs while increasing quality, allowing providers within these organizations to offer their utmost best care while retaining any savings achieved.  
To learn how adopting an MCO or ACO reimbursement model benefits your organization’s reimbursement objectives, check out our summary of findings from a Vision to Virtual session. As it stands, some newer ACO models under the CMS banner allow providers to assume greater financial risk—and rewardcompared to previous Medicare Shared Savings Programs, making this model very viable for nascent remote patient monitoring programs.  

4. How can physician groups support reimbursement?  

Partnering with a physician group allows healthcare organizations providing telehealth and remote monitoring services to offer their services and obtain compensation while keeping lower headcounts. The physician group works with your staff to review data on patient conditions and coordinate patient conditions data and coordinate any changes to care plans. They also submit claims on your behalf to CMS, using the appropriate NPI, Tax ID, or codes.  
We recommend physician groups to healthcare providers that work closely with or are part of an ACO. Thanks to lower manpower needs and costs, providers can take on higher-risk Medicare Advantage patients while preserving their investment returns investment for doing so.