Remote Patient Monitoring Billing, Credentialing

There are significant potential benefits to RPM including:

• Increased access to care and reduced costs – Patients can be monitored wherever they are instead of having to visit clinics frequently. This saves time and money for both providers and patients.
• Improved outcomes – Closer monitoring enables earlier interventions when health declines and preemptive care. Studies show RPM improves outcomes for chronic conditions like diabetes, heart failure and COPD.
• More personalized care – Having real-time data enables providers to track vitals and symptoms specific to each patient for customized treatment plans.
• Patient engagement – RPM empowers patients to be more involved in their health through self-monitoring. This enhances their knowledge and motivation to follow care plans.

While promising, remote patient monitoring also poses new challenges, especially when it comes to proper billing and documentation to ensure services get reimbursed. This page provides an overview of RPM billing, including coding, eligibility, reimbursement and compliance considerations.

The main Current Procedural Terminology (CPT) codes to know for RPM billing are:

99453

Initial set-up and patient education on use of equipment. This code is for the initial provision of devices, instructions and set-up required prior to starting remote monitoring. It can be billed once per episode of care.

99454

Device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system (eg, heart rate, oxygen saturation, respiratory flow rate), each 30 days. This is for the monthly monitoring of physiologic data like heart rate, blood pressure, weight, etc. It can be billed once every 30 days.

99457

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. This is for monthly remote monitoring that involves live, interactive communication between providers and patients such as phone calls, video conferencing and online messaging.

99458

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month, each additional 20 minutes An add-on code for 99457 for each additional 20 minutes of interactive communication per month.

To bill for RPM, providers must use a combination of these CPT codes depending on the type and duration of monitoring and communication provided. Proper linking of the codes reflects the full scope of remote services.

There are specific billing rules and documentation that providers must follow to receive RPM reimbursement:

• Patient consent – Get written or verbal consent from the patient to receive RPM services prior to billing. Consent should be documented in the medical record.
• Medical necessity – Establish that RPM is medically necessary for the patient based on their condition. Include an order from the billing practitioner recommending RPM.
• Face-to-face visit – An initial in-person visit is required to determine medical necessity and give RPM instructions. This is billed separately from RPM codes.
• Interaction – For codes 99457 and 99458, there must be two-way, live communication between provider and patient such as phone, email or portal messaging. One-way monitoring does not qualify.
• Time – For 99457, at least 20 minutes of interactive communication must occur each month. For 99458, each additional 20 minutes is billed on top of the base 20 minutes for 99457.
• Diagnosis codes – Include diagnosis codes reflecting the patient’s monitored conditions. Link the proper ICD-10 codes to CPT codes.
• Medical records – Document details of RPM services including parameters monitored, transmission frequency, communication and duration in the patient’s medical record.

Careful adherence to billing guidelines is necessary for compliant RPM billing. Providers should ensure all components are met prior to submitting claims.

Eligible practitioners include:

• Physicians
• Nurse practitioners
• Physician assistants
• Certified nurse midwives
• Clinical nurse specialists

Other qualified health professionals may provide aspects of RPM under physician supervision per Medicare policy including:

• Registered nurses
• Licensed practical nurses
• Medical assistants
• Certified diabetes educators

RPM services typically billed under a physician include:

• Equipment set-up
• Patient instructions
• Transmission of data
• Communication and education
• Treatment recommendations

Auxiliary staff may perform device setup, vitals transmission and non-complex patient communication. The extent of their involvement must be documented and appropriately supervised by the physician.

Considerations for coverage include:

Medicare

• Requires patient have a chronic condition such as COPD, diabetes or hypertension
• Initial in-person visit is reimbursed separately under regular evaluation and management codes
• 99453 for set-up can be billed once per episode of care
• 99454 for monitoring can be billed for up to 3 unrelated chronic conditions
• 20 minutes of interactive communication required for 99457

Commercial Insurance

• Policies are inconsistent between plans
• Some cover RPM for a wider range of conditions
• Time requirements may differ
• More favorably reimburse live video interactions

Medicaid

• Few States reimburse for RPM under Medicaid currently
• Coverage is largely limited to programs involving use of RPM
• Payment amounts and eligible codes can vary significantly

When verifying reimbursement, confirm details including eligible:

• CPT/HCPCS codes
• Providers
• Settings
• Technology
• Diagnosis codes
• Time requirements
  

RPM billing must meet general healthcare regulatory requirements including:

HIPAA

• RPM transmission systems must be HIPAA-compliant to protect patient privacy and data security

Stark Law

• Provides devices for free or below fair market value to induce patient referrals

Anti-kickback Statute

• Receive payments or other incentives from device manufacturers that improperly influence use of their products/services

Documentation and Coding Requirements

• All billed CPT codes must be properly documented
• Only bill for time spent on billable activities
• Use correct ICD codes that represent monitored conditions

In addition, RPM has some specific areas of concern:

Overutilization

• Use reasonable medical criteria for initiating RPM and ending services when no longer required. Avoid overuse solely for added reimbursement.

Technology Compliance

• Ensure RPM technology meets security and capability requirements for care standards and billing.

Advertising

• Marketing must not misrepresent RPM capabilities or guarantees of results. Have proper disclaimers.

With appropriate systems, technology, documentation, coding and responsible oversight, providers can implement RPM effectively while remaining compliant. Having clear policies will help avoid areas of risk and ensure services are provided and billed properly.