Managed Care ACO clinicians can provide remote patient monitoring, telehealth, and virtual care services to patients with acute and chronic conditions and for patients with only one disease.

An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions.

For example, managed care ACO may remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.

CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.

These services are not considered “telehealth” services and were never subject to telehealth limitations. They do have other factors that limit how they can be used so make sure you check the definition for the codes.

  • 21 state Medicaid programs provide reimbursement for remote patient monitoring (RPM).  As is the case for store-and-forward, two Medicaid programs (HI and NJ) have laws requiring Medicaid to reimburse for RPM but at the time the research was conducted, did not have any official Medicaid policy.

The Remote Patient Monitoring questions and answers for managed care ACO posted here are provided for general informational purposes only and were current as of the publication date. Due to the evolving nature of the industry, updated or new guidance and clarifications from the governing agencies and your particular circumstances, your results with insurance billing/reimbursement may vary. CENSON Health in no way guarantees or warrants any particular result to be obtained from use of the information on this page. You should consult with your billing provider for the latest information, and for additional codes that have become available during the COVID-19 pandemic. 

Yes. Even before the new codes, Medicare already offered separate reimbursement for RPM services billed under CPT code 99091. That service is defined as the “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.”

While industry advocates generally applauded CMS for activating CPT 99091, they recognized how that code fails to optimally describe how RPM services are furnished using current technology and staffing models. These are the codes CMS finalized effective in 2019, which do a far better job in accurately reflecting contemporary RPM services.

The new Chronic Care Remote Physiologic Monitoring codes are:

CPT code 99453:

“Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”

Reimbursement Rate: Approximately $21.00 (one-time)

CPT code 99454:

“16 days of Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”

Reimbursement Rate: $69.00 (every 30 days per patient)

CPT code 99457:

“Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”

Reimbursement Rate: $54.00 (each calendar month per patient)

CPT code 99458:

“Add-on code for patients who receive an additional 20 minutes of RPM services in a given month (i.e. 40 minutes of RPM services)

Reimbursement Rate: $43.00 (each calendar month per patient)

At least 20 minutes per calendar month. This differs from CPT 99091, which requires at least 30 minutes per 30-day period. CPT 99457 is much easier to track because it is based on a calendar month, not 30-day periods. This will more easily align with record keeping and claims submission, as CPT 99457 is reimbursed on a monthly basis.

Many advocates asked CMS to clarify the kinds of technology are covered under CPT codes 99453, 99454, and 99457. Some groups gave examples of the kinds of technology they believe these codes should cover, such as software applications that could be integrated into a beneficiary’s smartphone, Holter-Monitors, Wearables, or artificial intelligence messaging. Other examples included behavioral health data and data from wellness applications, or results of patients’ self-care tasks. Unfortunately, CMS did not offer any specifics in the final rule on what technology qualifies, but CMS does plan to issue forthcoming guidance to help inform practitioners and stakeholders on these issues.

CPT 99457 allows RPM services to be performed by the physician, qualified healthcare professional, or clinical staff. Clinical staff includes, for example, RNs and medical assistants (subject to state law scope of practice and state law supervision requirements). The inclusion of “clinical staff” is the most significant differentiator from CPT 99091, as that code is limited only to “physicians and qualified health care professionals.” All practitioners must practice in accordance with applicable state law and scope of practice laws. The term “other qualified healthcare professionals” used in CPT 99457 is a defined term, and that definition can be found in the CPT Codebook.

Yes. CPT code 99457 may be furnished by auxiliary personnel, “incident to” the billing practitioner’s professional services. An “incident to” service is one that is performed under the supervision of a physician (broadly defined), and billed to Medicare in the name of the physician, subject to certain requirements. As of January 1, 2020 Medicare has shifted from direct supervision to general supervision. Therefore, CPT codes 99457 and 99458 falls under general supervision — i.e. the physician and auxiliary personnel are NOT required to be in the same building at the same time.

Yes. CPT 99453 offers separate reimbursement for the initial work associated with on-boarding a new patient, setting up the equipment, and patient education on use of the equipment.

Yes, patients can receive RPM services in their homes.

RPM services do not require the use of interactive audio-video, as these codes are inherently non face-to-face. A face to face visit is not required.

Yes, the practitioner must get the patient’s consent for RPM services and document it in the patient’s medical record.

One patient could be enrolled in two different providers RPM programs, however, the same time and activities could not be double counted by both providers for purposes of billing any of the four codes.

It is important to note that neither RPM nor CCM are Telehealth services as defined by Medicare and therefore not subject to the restrictive requirements applicable to the location of the patient, type of provider, and type of technology. RPM 99457 may be reported during the same service period as CCM services, TCM services and BHI services. However, time spent providing any of these services should remain separate and no time should be counted toward the required time for more than one type of service.

Yes, a provider can bill both CPT 99457 and CPT 99490 in the same month. This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting). Accordingly, billing both requires at least 40 minutes total (20 minutes of CCM and 20 minutes of RPM).

CPT code 99454 covers the provision and monitoring during at least 16 days of 30 days. In other words, the device must transmit data for a minimum of 16 days within a 30-day period.