Today, most remote patient monitoring services are billed under four Current Procedural Terminology codes. These codes can be split into two categories to help understand their uses. There are two RPM device monitoring codes – 99453 and 99454 – and two timed RPM management service codes – 99457 and 99458.
CPT 99453 covers the time it takes to enroll patients in RPM and get them set up on their devices. It can only be billed once per patient enrollment. CPT 99454 is the monthly RPM code associated with monitoring and evaluating patient data transmitted from the connected device. Today, providers can only bill this code in a given 30-day period for patients who transmit at least 16 calendar days’ worth of device readings.
CPT 99457 is for spending a minimum of 20 minutes of clinical staff time providing care management services related to patient readings and their treatment plan. Finally, CPT 99458 is used when such clinical staff time reaches 40 minutes, and then a second 99458 can be billed at 60 minutes. These have been the four most common general RPM codes for a few years now.
Medicare was the first to cover RPM. Currently, it also is covered in some form by about 32 state Medicaid programs. Numerous commercial payers also cover RPM, sometimes within their telehealth coverage policies.
But things may be changing, and for the better. Providers soon may be able to bill for much more remote patient monitoring. The proposed changes are currently on the public agenda for the American Medical Association’s May CPT Editorial Panel meeting. There are three particularly significant changes AMA is considering for RPM that will be discussed at the meeting.
Daniel Tashnek is founder of Prevounce, which offers software, connected devices and care management services that aim to make preventive chronic care and remote patient monitoring programs easy to implement and scale. He is an expert in RPM coding. We sat down with him to discuss the proposed coding changes.
Q. Please summarize the proposed changes to RPM coding by the American Medical Association.
A. The first – and this would be a very big deal – is the addition of a code that would cover two to 15 calendar days of collected and transmitted data. CPT 99454, the only current general RPM device supply CPT code, can only be used when a provider has received and recorded 16 or more days of patient data within a 30-day period.
The addition of a new code would enable providers to code for those 30-day periods where fewer than 16 but at least two readings are captured.
The second noteworthy 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.
Revising 99457 would decrease the amount of time a provider’s clinical staff needs to provide RPM monitoring and care management time for a patient during the month to report the code.
The third is a revision of CPT 99458 to cover each additional 10 minutes of interactive communication. 99458 currently requires at least an additional 20 minutes of interactive communication. Revising 99458 would reduce the amount of additional time clinical staff must spend to report the code.
Q. What is the rationale for the changes?
A. The AMA has yet to offer any public argument for why it is considering these substantial changes. We will learn more about the rationale during the CPT Editorial Meeting in May. From my personal perspective, the proposed changes make sense for several reasons.
When developing the general remote patient monitoring codes, the AMA had to strike a balance between restricting the billing for de minimis or unreasonable monitoring programs while still allowing for innovation as new monitoring programs were created and studied.
The 99454 RPM code was the first economically viable remote monitoring code that did not explicitly specify a device type. Since the code was device agnostic, the AMA had to rethink how it had structured its criteria in the past to ensure there were incentives to design and implement beneficial monitoring programs. They landed on a 16 measurement-days per 30-day period requirement as a compromise, and it was clear they would be watching to see if they struck the right balance.
Since that time, there has been a growing body of clinical research showing that well-crafted RPM programs can improve patient outcomes while often reducing healthcare costs. Many clinical practitioners of RPM have submitted comments throughout the years that the 16 measurement-day requirement arbitrarily restricts many beneficial monitoring programs where fewer measurements are clinically adequate.
The same goes for spending 11 to 19 minutes on care management under 99457. Currently, what happens if a provider spends 15 minutes educating and managing a patient who is on an RPM program? The provider is delivering a valuable service to the patient but is currently not eligible for reimbursement.
That is likely to discourage providers from continuing to support this patient and stifle growth of an RPM program.
The changes under consideration generally seem designed to promote higher RPM adoption and more program flexibility by lowering the barrier to entry for both patients and providers. Rebalancing the codes given what we have learned since their initial release can better help ensure providers are paid appropriately for their time and services while still guarding against frivolous or unreasonable monitoring programs.
Q. What is the potential impact on providers with remote patient monitoring programs?
A. The AMA’s public agenda gives us only a summary of the changes under consideration, but from what we can see, the changes as written could significantly expand the scope of both existing and new RPM programs. Since the adjustments only expand the allowable criteria, existing RPM programs could continue doing exactly what they are currently doing without much change.
If the AMA approves the changes under consideration, and Medicare follows suit, which it usually does, then providers who make modifications and expand their RPM programs to fit the new codes will gain the most benefits for their patients and their clinics.
The same is true of any private payers and health plans that modify their coding rules to align with the AMA changes. Providers should make sure their RPM software and service vendors are keeping up to date and their systems reflect the changes to maintain compliant coding and billing.
Once the dust has cleared, we will be left with a wider range of conditions and patients that can be managed with RPM. Some specific modalities that can legitimately be performed with a lighter patient touch will become viable. I expect medical weight loss RPM programs to become more common, as one example.
It is also worth noting that Medicare is not necessarily required to update its coding rules to reflect AMA’s CPT code rules. However, the federal agency often does so. Private payers and health plans can choose not to update to the new code sets, but they rarely deviate from AMA’s rules.
If AMA makes these changes to RPM codes, coverage changes would most likely go into effect in 2025 or later.
Q. What are some insights you glean from the direction the AMA is considering?
A. While this expansion of the RPM codes is only under consideration by AMA at the moment, I believe we’re seeing the association further acknowledging the significant value of remote care management services like RPM and a desire to explore how it can further motivate providers to launch programs and help those with existing programs grow them to include more patients.
Although those of us in the industry hear rumors about overutilization and fly-by-night monitoring vendors, the AMA and Medicare obviously see the value in well-crafted remote monitoring programs. I believe the consideration of these changes to be part of an ongoing effort to expand the parts of RPM that work while starting to campaign against those who skirt around or abuse the codes.
From a macro view, we are facing growing shortages in physicians and other clinical staff positions. Care management services like RPM are helping address ongoing patient needs while reducing the number of in-person office visits. RPM is also helping to steer patients in the right direction for their care, which can help reduce the number of unnecessary hospital and in-office visits.
There has also been an increased focus on rural Americans, who face numerous health disparities compared with those living in urban areas. Rural populations experience a higher prevalence of chronic conditions on top of higher barriers to receiving care.
AMA has been working to address these challenges through various initiatives, and the expansion of care management services can undoubtedly play a role in helping bridge the gap in care. Medicare just expanded rural RPM programs by allowing separate RPM reimbursement to federally qualified health centers and rural health clinics.
The AMA expanding the RPM codes would only help encourage further adoption, which, if done correctly, would be particularly effective at helping lower rural disparities.
I am hopeful that AMA will follow through on the changes it’s considering. Assuming this happens, I hope Medicare and other payers will do so as well while setting reimbursement rates at amounts that encourage even greater adoption and growth.
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