Today, most remote patient monitoring services are billed under four applicable Procedural Terminology codes. These codes can be divided into two categories to help understand their usage. There are two RPM device monitoring codes – 99453 and 99454 – and two RPM time management service codes – 99457 and 99458.
CPT 99453 covers the time required to enroll patients in RPM and set them up on their devices. It can only be billed once per patient registration. CPT 99454 is a monthly RPM code related to monitoring and evaluating patient data transmitted from connected devices. Today, providers can only bill this code within a given 30-day period for patients who transmit device readings for at least 16 calendar days.
CPT 99457 is for clinical staff to spend a minimum of 20 minutes providing care management services related to patient metrics and their treatment plans. Finally, CPT 99458 is used when such clinical staff time reaches 40 minutes and then a second 99458 can be charged after 60 minutes. These are the four most popular generic RPM codes for several years now.
Medicare was the first to pay for RPM. Currently, it is also covered in some form by approx 32 state Medicaid programs. Many commercial payers also cover RPM, sometimes as part of their telemedicine insurance policies.
But things may be changing, and for the better. Providers may soon be able to charge even more Remote patient monitoring. The proposed changes are currently on the public agenda at the American Medical Association’s May CPT Editorial Board meeting. There are three particularly important changes that the CPT Editorial Board is considering for RPM that will be discussed at the meeting.
Daniel Tashnek is the founder of Prevounce, a company that provides software, connected devices, and care management services aimed at making chronic preventive care programs and remote patient monitoring easy. deploy and scale up. He is an expert in RPM coding. We sat down with him to discuss the proposed coding changes.
Ask. Please summarize the proposed changes to RPM coding for the May CPT Editorial Board meeting convened by the American Medical Association.
ONE. The first – and this will be a huge deal – is the addition of a code that covers data collected and transmitted between two and 15 calendar days. CPT 99454, the only generic RPM device provisioning CPT code currently available, can only be used when the provider has received and recorded 16 or more days of patient data within a 30-day period.
The addition of the new code will allow providers to code within a 30-day period that has fewer than 16 but at least two recorded readings.
The second notable change under consideration is a revision of CPT 99457 to include 11-20 minutes of RPM care management time. 99457 currently requires at least 20 minutes of recorded care management time.
Revision to 99457 will reduce the amount of time a provider’s clinical staff needs to provide RPM monitoring and care management to the patient during the month for code reporting.
The third is a revision of CPT 99458 to include each additional 10 minutes of interactive communication. 99458 currently requires at least 20 minutes of interactive communication. Amendment 99458 will reduce the amount of additional time clinical staff must spend reporting the rule.
Q. What is the reason for these changes?
ONE. There has not yet been any public argument for these significant changes. We’ll learn more about why in the CPT Editorial Meeting in May. From my personal perspective, the proposed changes make sense for many reasons.
When developing overall remote patient monitoring code, the CPT code set must strike a balance between limiting payments for monitoring programs to minimal or unreasonable levels while still allowing for innovation when monitoring programs newly created and researched.
Code 99454 RPM is the first cost-effective remote monitoring code that does not explicitly specify the device type. Because the code is device agnostic, the CPT Editorial Board had to rethink how they had previously structured their criteria to ensure there were incentives to design and deploy effective monitoring programs. profit. They offered a request for 16 days of measurements in a 30-day period as a compromise, and obviously they’ll be watching to see if they’ve achieved the right balance.
Since that time, a growing number of clinical studies have shown that well-constructed RPM programs can improve patient outcomes while often reducing health care costs. Many RPM clinical practitioners have submitted comments over the years that the 16-day measurement requirement arbitrarily limits many beneficial monitoring programs in which fewer measurements are clinically sufficient.
The same goes for spending 11 to 19 minutes on care management under 99457. Now, what if providers spent 15 minutes educating and managing patients participating in the RPM program ? The provider is providing a valuable service to the patient but is not currently eligible for reimbursement.
That could discourage providers from continuing to support these patients and stifle growth of the RPM program.
The changes under consideration generally appear designed to promote higher RPM adoption and more program flexibility by lowering barriers to entry for both patients and providers. Rebalancing the codes based on what we’ve learned since the initial release can help better ensure providers are properly compensated for their time and services while still addressing prevent frivolous or unreasonable surveillance programs.
Q. What is the potential impact on remote patient monitoring program providers?
ONE. The May meeting’s public agenda only gives us a summary of the changes being considered, but from what we can see, the changes written down could expand significantly. List the scope of both the current RPM program and the new RPM program. Since the adjustments only expand the allowable criteria, existing RPM programs can continue to do exactly what they are doing without much change.
If the changes under consideration are approved and Medicare follows suit, which is often the case, providers that modify and expand their RPM programs to conform to the new rules will gain the most benefits for patients and their clinics.
The same is true for any private payers and health plans that modify their coding rules to accommodate changes to the CPT code set. Suppliers must ensure that their service provider and RPM software are kept up to date and that their systems reflect changes to maintain encryption and billing compliance.
Once the dust clears, we will be left with many more conditions and patients that can be managed with RPM. Certain specific procedures that can be performed legally with gentler patient contact will become feasible. I hope medical weight loss RPM programs will become more popular, as an example.
It is also important to note that Medicare does not necessarily update its coding rules to reflect the AMA’s CPT coding guidelines. However, federal agencies often do so. Private payers and health plans may choose not to update the new code, but they rarely deviate from CPT guidelines.
If changes are made to the RPM code, the coverage changes will most likely take effect in 2025 or later.
Ask. What insights do you have from the direction the CPT Editorial Board is considering?
ONE. Although this expansion of the RPM code is currently only under consideration by the CPT Editorial Board, I believe we are seeing further recognition by the association of the important value of remote care management services like RPM and look forward to wanted to explore how it could motivate further. providers launch programs and help those with existing programs grow them to attract more patients.
Although those of us in the industry hear rumors about overuse and nightly monitoring by providers, the AMA and Medicare clearly see the value of remote monitoring programs that are carefully built. I believe that reviewing these changes is part of an ongoing effort to expand the working parts of RPM while also starting a campaign against those who circumvent or abuse the code.
From a macro perspective, we are facing a growing shortage of physician and other clinical staff positions. Care management services like RPM are helping to address ongoing patient needs while reducing in-person office visits. RPM is also helping steer patients in the right direction through their care, which can help reduce unnecessary hospital visits and clinic visits.
There is also increasing focus on rural Americans, who face many health disparities compared to those living in urban areas. Rural populations have higher rates of chronic diseases due to higher barriers to receiving care.
The AMA has been working to address these challenges through a variety of initiatives, and expanding care management services can certainly play a role in helping close the gap in care. Medicare recently expanded rural RPM programs by allowing separate RPM reimbursement for federally qualified rural health clinics and health centers.
The CPT Editorial Board expanding the RPM code would only help encourage further adoption, which, if done properly, would be especially effective in helping reduce rural disparities.
I hope that the CPT Editorial Board will follow through with the changes they are considering. Assuming this happens, I expect Medicare and other payers to do the same while setting reimbursement rates at levels that encourage even more adoption and growth.
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