Medicare RPM FAQs for 2021

RPM: The Basics

What is RPM?

Remote Physiologic Monitoring (RPM) involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.

Is RPM new?

In short, RPM is not new. In 2019, CMS created new reimbursement codes for connected care services that enable providers to manage and coordinate patient care remotely. In 2020, CMS expanded this opportunity with additional reimbursement codes. Together, these codes are referred to as RPM. The four primary Medicare RPM codes are CPT codes 99453, 99454, 99457, and 99458.

How does RPM work?

RPM involves the use of a device (for example, a cellular-enabled weight scale or blood pressure cuff) that collects and transmits patient data wirelessly to a provider. This collected data allows a provider to monitor changes in patient vital signs and act accordingly.

Reimbursement

Which CPT codes* are used for RPM reimbursement?

• Patient onboarding & education: CPT code 99453 ($19.19) | Reimbursement for the initial, one-time cost of device set-up and educating the patient about RPM. Once per episode of care.
• Device supply with ≥ 16 days of RPM: CPT code 99454 ($63.16) | Reimbursement for the supply of the RPM device, which must transmit patient data for at least 16 days per month. Each 30 days.
• Monitoring with communication, first 20 minutes: CPT code 99457 ($50.94) | Reimbursement for treatment management services, requiring interactive communication (includes both in-person and connected health channels) with the patient/caregiver. Each calendar month.
• Monitoring with communication, additional 20 minutes: CPT code 99458 ($41.17) | Add-on code: each additional 20 minutes of treatment management services. Each calendar month, up to 2x.

*These are average Medicare rates. Actual reimbursement varies by MAC locality.

How are providers reimbursed for RPM?

Every month, providers can submit claims and receive reimbursement from Medicare for RPM services. In addition, there is a one-time reimbursement for set-up and patient education. Reimbursement rates from private payers vary, but many base what they pay on CMS rates.

Who can order and bill for RPM services?

RPM codes are considered Evaluation and Management (E/M) services. Despite requests to allow other providers to bill for RPM services, the 2021 Final Rule confirmed RPM can only be ordered and billed by physicians or non-physician practitioners who are eligible to bill Medicare for E/M services.

How much can you expect to get paid for RPM?

For an individual patient, initial enrollment (CPT code 99453) generates a single payment from Medicare of about $19. After that, practices providing ongoing RPM services can bill CMS on a monthly basis. There is a base monthly RPM payment (CPT code 99454) that earns practices about $63 for supplying the monitoring device. These two codes are not to be reported for a patient more than once during a 30-day period.

The first 20 minutes of care management services, covered under CPT code 99457, averages a payment of $51. Most patients will require no more than 20 minutes of clinical staff time per month. For patients requiring more than 20 minutes, practices can submit CPT code 99458 (averages a payment of $42) to cover an additional 20 minutes of care management services. If patients need more than 40 minutes, practices can bill CPT code 99458 once more and be reimbursed the same $42 rate. Practices cannot bill more than 60 minutes of care management services per month.

Summary of RPM Billing Requirements:

• Patients must opt-in for the service.

• The device must meet the FDA’s definition of medical device.

• The medical device must be defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act and be reliable and valid.

• Devices must supply data ≥ 16 days to be applied to a billing period.

• Service must be ordered by a physician or other qualified healthcare professional.

• The data must be electronically collected and transmitted (rather than self-reported).

• Data-monitoring services may be performed by the physician, by a qualified healthcare professional or by clinical staff. Clinical staff may include RNs and medical assistants, depending on state law.

Enrollment Requirements

Who can furnish RPM services and obtain consent?

Auxiliary personnel, in addition to clinical staff, can furnish services described by CPT codes 99453 and 99454 (patient education and RPM device set-up) under the general supervision of the billing physician or practitioner. Auxiliary personnel include other individuals who are not clinical staff but are employees, or leased or contracted employees. This includes contracted employees, such as Veta Health.

CPT codes 99457 and 99458 can be furnished by a physician, other qualified healthcare professional, or clinical staff under the general supervision of the physician.

Must the patient have a chronic condition to be eligible for RPM?

RPM can be used for patients with acute and chronic conditions.

How does patient consent work?

• A single annual consent for services must be obtained.

• Consent can be obtained at the time RPM services are furnished.

• Consent can be obtained by individuals under contract with the billing physician or qualified healthcare professional.

• Verbal consent is acceptable and should be documented in the patient’s medical record.

Can RPM be used with new and established patients, alike?

Patients who have not seen their provider within one year must have an in-person visit before RPM billing may occur. Physicals and annual exams, traditional care management services, and E/M services can count, since they have separate Medicare billing codes.

Note: Starting March 1, 2020 and for the duration of the Public Health Emergency (PHE), RPM services can be furnished to both new and established patients (CMS). When the PHE ends, CMS will require that RPM services must be furnished only to established patients. CMS’ waiver suggests that during the PHE, practitioners may render RPM services without first conducting a new patient E/M service.