In 2018, the Centers for Medicare & Medicaid Services (CMS) started reimbursing remote patient monitoring (RPM), a subset of telehealth, with the creation of the Current Procedural Terminology (CPT) code 99091. This allowed physicians to bill for interpretation and monitoring of physiologic data such as blood pressure and glucose monitoring from the patient’s home. Since then, RPM services have evolved, and the CPT codes have expanded from one to five. Using these codes allows for reimbursement of the device’s setup, ongoing monitoring, and interactive real-time communication between the patient and their healthcare provider. RPM allows providers to better manage their patients’ acute and chronic conditions, improving quality and access to care. With the COVID-19 public health emergency, the use of RPM services—like other telehealth services—saw rapid growth. The increase in the use of RPM services can be cause for concern with respect to possible compliance issues; thus, the announcement by the U.S. Department of Health and Human Services Office of Inspector General (OIG) in 2021 that audits would be conducted in two phases and that RPM services would be included in phase two was not surprising.
Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.[1]
This article will focus on the potential billing and coding compliance issues that healthcare providers and compliance officers should be aware of to avoid denials.
Understanding the RPM CPT codes is important to billing compliance
Although the first RPM CPT service became billable in 2018 with CPT code 99091, the current RPM codes under the Physician Fee Schedule were implemented on January 1, 2019. The code expansion was necessary to reflect what is involved in the delivery of RPM services. “In this final rule for CY 2021, we continue our work to improve payment for care management services through code refinements related to remote physiologic monitoring (RPM), transitional care management (TCM), and psychiatric collaborative care model (CoCM) services.”[2] There are two codes to report physiologic monitoring: 99453 and 99454. The first code, 99453, is for the initial setup and patient device education, and the second code, 99494, is for device daily recording(s) or programmed alerts transmission. Additionally, two codes can be used for remote physiologic monitoring treatment management services—99457 and 99458. Both RPM treatment management codes are timed CPT codes. The use of these codes requires live, interactive communication between the healthcare provider and the patient or caregiver. The time spent on care management services for the patient can also include the time spent, as clarified by CMS in 2021.
We clarified that for CPT codes 99457 and 99458, an ‘interactive communication’ is a conversation that occurs in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS [Healthcare Common Procedure Coding System] code G2012. We further clarified that the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.[3]
CPT code 99457 is used for the first 20 completed minutes of clinical staff/physician or other qualified healthcare professional time in a calendar month spent with the patient, and 99458 is for each additional, fully completed 20 minutes. A thorough understanding of each CPT code for RPM services is key to properly billing this code set.
