Typically an in-person initiating visit (if more than one year since last seen) and patient consent is documented in the patient’s medical record. Remote Patient Monitoring must be deemed medically necessary by provider. We recommend a way to track and record time spent monitoring a patient in the event of an audit for CPT 99457 (20 min of clinical or QHCP monitoring/interaction with patient over a calendar month) and for CPT 99091 (30 min of monitoring/interaction by QHCP with patient over thirty days).
Although it could be argued that a patient suffering from one or more chronic conditions may benefit equal to or greater than a non-chronic patient, CMS, on the Medicare side, has purposefully left open eligibility for a wider range of patients to benefit from the service.
CMS finalized the following three (3) RPM/Telemonitoring CPT Codes in 2019:
CPT 99453 (one time install of telemonitoring device and patient education)
CPT 99454 (ongoing supply of telemonitoring device(s) and physiological transmittals each 30 days)
CPT 99457 (monitoring and treatment management services / clinical/QHCP interaction with patient, 20-min in calendar month)
CPT 99091 (Collection and interpretation of physiologic data by QHCP/MD, 30 min of time over thirty days) was finalized by CMS in 2018/QHCP
Yes, physicians can provide and bill for TCM (99495 and 99496) and CCM services (99487, 99489, 99490 and 99491) in the same month as RPM/Telemonitoring. CMS recognized that telemonitoring has value apart and aside from other CCM services. The initiating visit for CCM or TCM can also count as the initiating visit for Telemonitoring, necessary if the patient has not been seen within the last 12 months. However, CMS has indicated that the double counting of time spent on a Telemonitoring code and a CCM Code is prohibited (i.e. 20 min spent on 99457 cannot be included as 20 min for 99489).
No, there is no certification process similar to that of State Medicaid Telemonitoring programs (which, for example, is a default 60-day period for Texas Medicaid). Consequently, there is no recertification process either. Patients are eligible to receive ongoing RPM services for as long as deemed medically necessary by the physician/QHCP, and service continues to be accepted by the patient.
No - unlike State Telemonitoring guidelines, there is currently no Pre-Authorization protocol or portal, similar to that of TMHP.
Yes - can't bill 99457 and 99091 within 30 days of each other for same patient within same practice.
The short answer is No; however, CMS will be monitoring for abusive practices, and RPM should only be used for as long as deemed medically necessary.
Yes – RPM/Telemonitoring services are rapidly growing in several specialty fields, including but not limited to, Pediatrics, Mental Health, OB/GYN, Pain Management, etc. Combining Telemonitoring with Telehealth services is also expected to grow for these specialties as well as others.
Yes, RPM/Telemonitoring is available and encouraged for patients with ESRD, and may be bundled under a patient’s dialysis treatment, and may count towards a capitated rate for ESRD services.
The Rule states that CPT Code 99457 describes only professional time and “therefore cannot be furnished by auxiliary personnel incident to a practitioner's professional services”. This position is in stark contrast to CMS’s current stance on traditional CCM services, whereby CMS has not only allowed the services to be billed “incident to” but has also allowed the incident to services to be performed under general supervision rather than the more strict direct supervision as is typically required for incident to billing. This position also appears to contradict the descriptor of Code 99457 itself, which states the services can be furnished by clinical staff. We have been in contact with CMS and it’s expected they will publish a technical revision to make clear that these services can be provided “incident to”.
Assuming “incident to” billing will be permitted, there is nothing to prohibit a physician practice from contracting with a Home Health agency to provide RPM services, similar to the way CCM services are contracted out and provided “incident to.” The contracting provider of RPM services should have the appropriate agreements in place (BAA, Services Agreement, etc.) with the physician practice.
CPT Code 99457 allows for reimbursement for time spent by the billing physician, a qualified healthcare professional (QCHP), or clinical staff in monitoring and interacting with the patient data. All practitioners must practice in accordance with applicable state law and scope of practice laws. There is no specific guideline for review and action of physiological transmittals; however, the spirit of Telemonitoring is to view a patient's trends over time, intervene when necessary, make medical decisions accordingly, and reduce costly insurable events before they occur (i.e. Emergency Care). CPT Code 99457 is billed monthly.
CPT Code 99453 is one-time billing. CPT Code 99457 is billed once each calendar month, and can commence on the 25th of January, or otherwise, commence billing the 1st of February for simplified administration. CPT Code 99457 requires 20 min of clinical interaction in a given calendar month; if the 20min is achieved between the 25th and 31st of January, it can be billed for that calendar month.
No, unlike some State Medicaid Telemonitoring reimbursement protocols, frequency of a patients physiological transmittals doesn’t directly impact reimbursements; however, CPT Code 99457 requires 20 min of healthcare professional interaction, which may be difficult to accomplish with low patient adherence. Under 99457, CMS envisions a device providing daily transmissions of PGHD; however, formal guidance is forthcoming. Code 99091 does not necessarily require daily transmission by device.
No, CPT Codes 99454 and 99457 do not prevent billing based on a combination of diagnosis codes, and any respective physiological readings. That said, if 20 min of professional clinical interaction is not met reviewing the physiological readings in a given month, CPT Code 99457 cannot be successfully billed.
Currently CMS has not provided formal guidance on the devices that can be used, but they intend to provide guidelines in the next couple of months. There is some concern about using data from iPhone apps. Under CPT Code 99454, FDA defined medical devices are allowed. Stay tuned for CMS updates to permissible devices.
Yes, RPM can be billed for by multiple providers in different specialties/practices for the same patient, but no one practice can bill for their monitoring of physiological data more than once per patient per month. Please also note the Medicare distinction between Telemonitoring and the Medicare CCM guidelines, in that a patient does not need to meet CCM criteria in order to participate in RPM.
The following are common CCM and Complex CCM codes that benefit Medicare patients under telemonitoring services:
CCM Code 99490 - ccm services, 20min clinical staff time, directed by physician/qhcp, 2 or more chronic conditions expected to last 12 months, comprehensive care plan, assumes 15 min of billing time
Complex CCM Code 99487 - 2 or more chronic conditions expected to last 12 months, requires moderate or high level of physician time, 60 min of physician time
Complex CCM Code 99489 - for each additional 30 min assuming the physician has maxed out 99487 for the given patient in a given month
CMS is not being restrictive on any use cases at this time. Purposefully, CMS would like to see which medical fields/specialties and the level of traction Telemonitoring receives. Basic physiological parameters, such as Blood Pressure, can provide a great deal of insight into the physical and mental state of a patient. CMS has specified that RPM codes may be used in conjunction with the Behavioral Health Integration codes.
CPT Code 99444 is currently not a code that is reimbursable by Medicare. CCM Codes 99487, 99489, and 99490 (Chronic Care Management Services) can be billed concurrent for chronic care patients. Many physician practices utilize CCM systems and will not be impacted by enlisting those patients to telemonitoring.
In 2018, CMS “unbundled” CPT Code 99091 making it available to bill for the Medicare Telemonitoring; however, it cannot be billed concurrent to 99457. Feedback from physicians after a year of Code 99091, was that physicians did not have 30 min, and needed a portion of the aggregate clinical time to be managed by additional clinical roles for triage and escalation. The unbundling of 99091, much like 99457, allows either code to be billed concurrent to TCM and CCM services.
No, 99457 and 99091 cannot be billed in the same month for the same patient, it’s one or the other.
The most significant change was delineating RPM/Telemonitoring from the overarching umbrella of Telehealth, making the distinction that Telemonitoring services were not restricted to Telehealth rules (i.e. Originating Site and rural/underserved geography restrictions). The goal is to promote the collection of physiological time trends to better prevent unnecessary health events and costs.
Common use cases would be triage of critical or at risk alerts, cross referencing additional patient information, reviewing the patient's trend charts, contacting the patient, any necessary medical interventions, and making note of all these tasks and using a tool or set of tools that can capture the time spent doing so. CMS ultimately is looking for “reasonableness” in the accounting of time spent for Code 99457 or 99091; they are intentionally being less restrictive to allow for innovation, and after some time will look for abuse to come up with negative use cases in order to implement restrictive policies.
A reason to bill 99091 over 99457 could be the acuteness of the patient’s condition, and whether the Physician/QHCP required the majority of clinical time spent reviewing. Another common use case is “physical therapy” where a QHCP is the role that is doing the majority of the monitoring. A reason to bill 99457 over 99091 would be the reduction in clinical time spent during a month, and the level of clinician required to perform the task.
No, a patient can visit the physician without impacting the physician’s reimbursements for any of the RPM/Telemonitoring Codes (i.e 99457).
CPT Code 99457 can be fulfilled by Physician, QHCP, or other clinical staff. CPT Code 99091 is for physicians/QHCPs. There is no specific list of “QHCP” providers; they must simply be “qualified by licensure and/or training.”
RPM/Telemonitoring is not tied to chronic care conditions with respect to Medicare. It’s common place for a physician to refer a ccm patient for RPM/Telemonitoring, but it’s not required.
For example, if a patient was discharged and requires post-surgery monitoring, certain exercises or step counting could be used to evaluate progress.
Since there is no certification process required, there is no requirement to pause/commence Telemonitoring services for Medicare; however, the 20 or 30 minute time requirements must still be met in order to bill for the RPM services.
There is no prescription required, it’s simple documentation in the patient’s Electronic Medical Record, and documentation that the patient accepted the service. Medicare patients are also required to pay the Part B copay of 20%; they must be made aware that they will be billed the ~$9/month as the Medicare copay for the RPM/Telemonitoring service.
There is no max duration for time limit on telemonitoring for a specific patient. As long as the physician deems medical necessity, and the patient accepts service.
For TCM, the initiating visit can be made virtually under certain circumstances, and a TCM visit can qualify as an initiating visit for RPM services. However, it is not yet clear whether a virtual TCM visit can qualify as an initiating visit for RPM services. At this point, initiating visits should take place in a face-to-face in-person setting.
For telehealth services (as opposed to RPM services), Medicare requires that services be provided in an “Originating Site” in limited geographical rural or underserved area in order to be reimbursed. In such circumstances, there are ~101 telehealth CPT codes billable for Medicare.
Facility vs Non-Facility should be billed in accordance with whether the telehealth services take place in Facility or Non-Facility. For information on how to bill Medicare for Telehealth services, please see
Don’t believe so at this time; however, it’s expected that CMS and Office of Budgeting will review data from Medicare Telemonitoring to determine the efficacy. They are using non-governmental studies conducted by Research Institutes and Private Industry as the case for using Telemonitoring to save costs. Some small scale Pilots by CMS have also been a driver for expanding the use of Telemonitoring.