Detailed Answers to Your CPT Code Questions

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Detailed Answers to Your CPT Code Questions

To help you better understand the CPT codes for RPM reimbursement, here are answers to some common questions. We will keep you up-to-date as new information comes out, and we can help you address other issues if you contact us.

For background on the CPT codes that apply to RPM reimbursement, see our post Understanding the RPM CPT Codes.

Medicare Billing Requirements for RPM Patient Education and Device Supply

1. What requirements have CMS placed on the type of RPM device that qualifies for use under code 99454? Does CMS require that the device be FDA approved?

CMS did not state the specific types of technology that apply to code 99454 in the CMS-1693-F final rule; however, CMS has stated that the device must be a “medical device as defined by the FDA.”

While Medicare does not require the device to be “approved” or “cleared” by the FDA, a provider’s specific use of an RPM device with patients may require FDA approval. It is recommended that the provider obtain legal advice to determine FDA compliance obligations and whether the device meets the FDA’s definition.

We are committed to ensuring that devices supplied by RPM365 meet FDA requirements for RPM reimbursement.

2. If the RPM device does not automatically wirelessly transmit the patient’s data to the provider, can the data be manually entered from the device into an application on the patient’s smartphone or computer for transmission to the provider?

Many healthcare industry experts agree that the guidelines for code 99454 indicate that the RPM device must be able to record and transmit the patient’s data wirelessly to the provider. Based on available technology, this wireless transmission can likely occur when the RPM device is connected to a smartphone, tablet, or computer (mobile device) via a cable or Bluetooth®, both of which require some manual interaction with both the RPM device and a mobile device. Manual interactions should be limited to when patients tap function keys on their mobile device to:

          • Pair the medical device with the mobile device
          • Sync their physiological data from the medical device to the mobile device, or
          • Transmit the data wirelessly from the mobile device to the provider

For compliance with code 99454, and also for RPM codes 99453, 99457, and 99458, patients should not be required, nor permitted, to manually select certain data points from their RPM medical device to send to their providers.

3. If a qualified healthcare professional provides the initial setup and patient education on the use of the RPM device and equipment for two or more Medicare beneficiaries together as a group, on the same day, how would the billing for code 99453 be done?

CMS has not published billing guidance on this scenario, nor can healthcare industry experts look to Medicare’s telehealth guidelines, as CMS does not consider RPM a telehealth service. The code 99453 states “initial; setup and patient education on use of equipment.”  The code definition does not specifically state “individual” or “group,” as do other non-RPM procedure codes (e.g., G0108 for individual DSMT and G0109 for group DSMT).

The consensus of many healthcare industry experts is that if two or more patients receive the services defined by code 99453 in a group at the same time by the same qualified healthcare professional, and all other code requirements are met, then the billing provider may be able to submit a separate claim for each of the patients. We suggest that RPM billing providers contact the Medicare Administrative Contractor for their region and ask how billing in this scenario is to be done.

Medicare Billing for Multiple RPM Devices for a Single Patient

4. With regard to Medicare, if one beneficiary is being treated with two different RPM devices by two different physicians in two different practice settings (i.e. blood pressure monitoring prescribed by the cardiologist and blood glucose monitoring prescribed by the endocrinologist), can each physician bill the RPM code 99454 for the device supply?

Medicare has not specifically addressed this scenario to date. There are conflicting opinions here and more guidance from CMS is needed. Two common opinions among healthcare industry experts are:

A) Code 99454 can only be billed once per beneficiary each 30 days, regardless of whether the beneficiary is using one RPM device or multiple devices. Therefore, if a glucometer and a blood pressure cuff are both provided to a patient for use in RPM and each device meets all of the requirements for billing code 99454, the code could still only be billed once each 30 days for that beneficiary. The same answer would apply if the two physicians are in two different practice settings or are in the same practice group.

Note the word “devices” (plural) in the Federal Register Proposed Rule titled Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies, et al. published 8-17-20, in which CMS states: “CPT code 99454 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) is valued to include the medical device or devices supplied to the patient and the programming of the medical device for repeated monitoring.” In this document, CMS also stated: “Review of CPT prefatory language (CPT® 2020 Professional Codebook (hereafter, CPT Codebook), p. 42) provides additional information about the two PE only codes. For example, the CPT prefatory language indicates that monitoring must occur over at least 16 days of a 30-day period in order for CPT codes 99453 and 99454 to be billed. Additionally, these two codes are not to be reported for a patient more than once during a 30-day period. This language suggests that even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.” But these statements do not address devices whether these devices can be furnished by two or more billing providers.

B) The four RPM codes may be covered for the one beneficiary receiving RPM services from more than one physician in two or more different practices during the same month/same episode of care, if:

            • The beneficiary is an established patient with each physician and has consented to the RPM services by each physician in each different practice.
            • The physicians are monitoring different physiological parameters for this beneficiary.
            • Medical necessity has been established for monitoring these multiple parameters.
            • The time counted for the time-based RPM codes 99457 and 99458 is not duplicative with the two physicians.

5. Can two different billing providers in two different practice settings each bill RPM codes 99457 and 99458 for the same beneficiary in the same calendar month?

Yes, as long as the same amount of interaction communication times between the provider/clinical staff and the patient are not “double-counted” by each of the billing providers for purposes of billing these two RPM codes.

For example, if billing provider A (endocrinologist) is furnishing RPM for Martha, the beneficiary, for blood glucose monitoring and billing provider B (cardiologist) is furnishing  RPM for Martha for blood pressure monitoring, note that:

            • The interaction communication (IC) time accrued by billing provider A (and/or the clinical staff) to bill the time-based code 99457 must be separate and distinct from the IC time accrued by billing provider  B (and the clinical staff) to bill the same code 99457. The IC time accrued for blood glucose monitoring cannot be added to the IC time accrued for blood pressure monitoring. This would be “double counting,” which is not allowed.
            • The amount of IC time counted for codes 99547 and 99458 remain distinct by each billing provider for the same beneficiary in the same month.
            • All other requirements to bill Medicare for the RPM codes are met.

Regarding “interactive communication,” CMS stated in the Federal Register 2021 Proposed Rule (published on 8/17/20) titled Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies, et al.: “Thus, we are clarifying that “interactive communication” for purposes of CPT codes 99457 and 99458 involves, at a minimum, a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission. As indicated in the code descriptor for CPT code 99457, the interactive communication must total at least 20 minutes of interactive time with the patient over the course of a calendar month for CPT code 99457 to be reported. Each additional 20 minutes of interactive communication between the patient and the physician/nonphysician practitioner/clinical staff is reported using CPT code 99458.”

Other Reimbursement Questions

6. With regard to Medicare, can the provider bill code 99454 if there are either daily recording(s) OR programmed alert(s) transmission, each 30 days, and not necessarily both?

CMS has not specifically addressed this question, nor provided guidance on what these terms in the code definition mean; however, we do have a consensus of opinion of healthcare industry experts on these terms in code 99454:

        • Daily recordings are the physiological data that are wirelessly transmitted by the patient’s RPM device to the provider. (For example, blood glucose values that are transmitted by the patient’s Bluetooth®-enabled blood glucose meter.)
        • Alerts are visual and/or audible messages that are automatically generated to the provider’s RPM dashboard (the RPM software). These alerts occur when the patient’s physiological data points are outside of the target range or threshold that has been set for each individual patient by the provider.

Here is an example for a patient with diabetes: the target range for blood glucose is 70 to 180 mg/dl. The alert glucose value is set at >250 mg/dl by the provider. The provider or clinical staff programs this alert parameter into the RPM dashboard in the office for the patient when the RPM service is started. When an alert is generated on the dashboard, the provider or clinical staff determine the course of action to take with the patient.

When a large number of patients are on the RPM devices, the patient alerts help prioritize those patients that need to be contacted first. With high-quality RPM dashboards installed in the provider’s office, patient alerts are queued and can be arranged chronologically by date so that the provider and the provider’s clinical staff can readily identify patient alerts from the previous evening or before hours of operation. These automated alerts to the provider’s office are a key benefit of remote patient monitoring, as they result in enhanced and prompt patient care and safety.

7. CMS has not yet explained fully what is meant by “daily recording(s) or programmed alert(s) transmission each 30 days.” With regard to this part of the definition, does it mean: both in combination are expected (in any proportion), or either daily recordings or alerts are permissible? 

A) An intuitive interpretation to answer this question is that the RPM dashboard installed on the provider’s computer/EHR would be unable to generate patient “alerts” if there are no “daily recordings” of the patient’s physiological data being wirelessly transmitted to the dashboard. This would imply that any combination of daily recordings and alerts are acceptable, as long as these combined data have been received by the provider for at least 16 days in the 30-day period for billing code 99454. This interpretation of the “or” in the code definition implies “either, or”.

B) Another interpretation focuses on the word “or” in the code language. For many RPM systems, the provider can customize the office dashboard to 1) only generate “alerts” and notdaily recordings” of the patient’s data; or 2) only generate daily recordings and not alerts. But this seems to be very counterintuitive, as RPM systems are designed to do both to maximize the care of the patient.

DISCLAIMER from RPM Healthcare and Contributing Author Mary Ann Hodorowicz, RDN, CDCES, MBA, Certified Endocrinology Coder: This information is current as of September 17, 2020, and is intended for educational and reference purposes only and does not constitute legal, financial, medical, or other professional advice in any form. The information presented is subject to change by CMS, commercial health insurers, and other organizations at any moment, and is subject to interpretation by its legal representatives, end-users, and recipients. Please contact your local payer, Medicare Administrative Contractor, professional medical billers, and coders and/or legal counsel for interpretation of coding and coverage guidelines by healthcare insurers.

Detailed Answers to Your CPT Code Questions
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