As part of expanding value-based care under the MIPS program, the Centers for Medicare & Medicaid Services (CMS) has expanded reimbursement in the primary care setting for adopting systems and processes to encourage chronic care management (CCM).
One of these initiatives involves promoting the concept of chronic care remote patient monitoring (RPM). As the physician fee schedule (PFS) is increasingly dependent on MIPS for physicians outside any advanced alternative payment models (APMs), adopting and adapting strategies for chronic care RPM is of paramount concern.
What is chronic care RPM?
RPM attempts to bridge the gap in medical care between a patient’s regular office visits, allowing a medical practice to guide patients and caregivers when monitored physiologic parameters fluctuate outside acceptable ranges. In essence, it is designed to serve as an early warning system to allow a medical practice to intervene and adjust treatment regimens and medical care plans as appropriate. The intention is to reduce the amount of time a patient must wait prior to being evaluated by a qualified healthcare provider in the office setting.
The benefits of early intervention are presumed to be improved patient outcomes and reduced overall costs to third-party payers from potential hospitalizations or emergency department visits from exacerbations of chronic illnesses. With appropriate digital devices transmitting data to medical practices on a frequent basis with alerts for abnormal values, it is presumed that the outpatient provider may ultimately reduce the financial and medical burden associated with uncontrolled chronic illness.
How is RPM performed?
In conjunction with companies and suppliers that provide “medical-grade” equipment and the necessary communications framework to facilitate remote monitoring, qualified healthcare professionals can periodically monitor a patient’s physiologic parameters remotely outside the office setting. Many chronic illnesses can be monitored in this way if pertinent data is transmitted in a secure fashion via reliable internet connection. Many examples of these technologies and relevant chronic illnesses are listed in Table 1. Thus, if a Medicare beneficiary has a suitable internet connection and RPM-capable medical-grade devices in the setting of a pertinent chronic medical condition, the patient would be a prime candidate for RPM under CMS rules and regulations.
How is RPM billed?
In the 2018 PFS final rule, Medicare finalized separate payments for CPT® codes related to the concept of remote patient monitoring. These codes are highlighted in Table 2. Based on input from the AMA/Specialty Society RVS Update Committee (RUC) in September 2017, the CPT editorial panel revised and unbundled the original chronic care management remote physiologic monitoring code (99091) and created three others (99453, 99454, 99457) to more accurately reflect a more diverse nature to the type of care described based on projected practice expense and provider input.
Both CPT® codes 99453 and 99454 are practice-expense-only codes without any attributable RVUs; however, CPT® code 99457 is slated to have a healthcare provider associated RVU value of 0.61 based on RUC recommendations. Specifically, for 99457, CMS stipulated that this code is only independently billable by qualified healthcare professionals who do not require direct oversight to practice within the scope of their license based on state regulations. As this may vary by state, the appropriateness for using the CPT® code may require review of relevant state definitions to remain in compliance with these requirements, as there may be ambiguity regarding healthcare providers other than physicians who are considered “qualified” for billable purposes.
For those familiar with the previous CPT code, 99091, many fundamental philosophies remain in place within the three new, expanded CPT® codes. These codes are better suited toward the individualized nature of the associated costs in relation to practice expense versus RVU based upon the need for direct, qualified healthcare provider input versus overhead costs for implementation of necessary IT infrastructure to receive RPM data and a HIPAA-compliant manner.
Both CPT® codes 99453 and 99454 describe practice-associated expenses and include tasks that, if necessary, can be performed by auxiliary personnel incidental to the direct application of the qualified healthcare provider’s professional services. In contrast, CPT® code 99457 is specifically designed to be billable by qualified healthcare providers separate from a bundled practice-expense-inclusive CPT® code to independently reflect individualized effort expended in adjusting treatment regimens and providing medical guidance.
CMS stated in the November 2018 changes to rules and regulations that CPT® code 99457 directly reflects professional time and direct effort spent by a qualified healthcare provider in direct medical management of a patient’s remotely transmitted physiologic data. This is explicitly stated to be for a total time no less than 20 minutes per calendar month. CMS elaborated that 99457 can only be billable under those parameters, thus documentation must reflect this fact to be reimbursable. Establishing a monthly workflow that incorporates time to adequately review RPM data is crucial to capture this source of revenue adequately.
Of further note, 99453 is only billable once at the time of initiating RPM, and both 99454 and 99457 can be billed approximately once per calendar month jointly as long as the patient continues to use RPM devices compliant with CMS regulations with transmitted daily recordings or programmed alerts, and the physician reviews physiologic data with interactive communication with the patient/caregiver for at least 20 minutes per calendar month, both respectively. It is crucial to verify that patients are appropriately using the devices essential to RPM and that an adequate cyclical billing cycle appropriately reflects this.1
It appears that chronic care management codes such as 99091 and 99490 can also be billed on a recurring monthly basis as long as specific criteria for each code are met that do not overlap with the three other RPM CPT® codes listed (see Table 3). Although rules regarding this may change in the future, it appears that if there is no distinctive overlap between the documented times that either CPT® code 99091, 99490 or 99457 was billed, all three may be potentially billed based on appropriate documentation specifically citing non-overlapping times that medical care was delivered meeting these parameters outside of other billable E/M visits.
As CMS has not specified the nature and types of technology that would be specifically covered under these new CPT® codes, there have been many questions surrounding the characteristics necessary to meet CMS requirements. CMS is planning to issue further guidance moving forward to help inform both patients and qualified healthcare providers in periodic updates. Further updates will also likely come in the form of revisions to the definitions of CPT® codes or possible future unbundling of existing codes to further account for associated costs and to reflect appropriate RVU adjustments over time. Given that these three new RPM codes were derived from a solitary CCM code introduced in the past fiscal year, it is likely that there will be further refinements as practices continue to embrace CCM and the necessary infrastructure to sustainably use RPM technology in a cost-effective way.
- “What you need to know about 2019 Medicare CPT codes for remote patient monitoring (RPM) – 99453, 99454 and 99457.” Pillsy. Dec. 11, 2018. Available from: bit.ly/2XNEN3e.
- “Remote patient monitoring (RPM).” Carematix. Accessed May 25, 2019. Available from: cpt99454.com.