Reimbursement Codes & Revenues
CMS REIMBURSEMENT
With Remote Patient Monitoring (RPM), providers can leverage physiological data to improve chronic disease management. Covered by Medicare Part B, it's imperative for providers to familiarize themselves with the CPT billing codes applicable to RPM to optimize care delivery and prevent claim denials.
RPM is a covered service for Medicare Part B patients with a nominal co-pay. This monthly program offers patients personalized care plans, ongoing engagement from the care team, and informed management of their conditions.Under Medicare's Physician Fee Schedule, RPM is reimbursable at various rates. Here are some essential details regarding RPM * CPT Codes: 99457, 99453, 99454, and others. These remote monitoring CPT codes correspond to specific activities, such as device setup or care provision, each with its own reimbursement rates and restrictions. For instance, providers typically receive $48.14 for 20 minutes of service per patient per month (99457).
Additional opportunities for higher billing thresholds exist, such as an additional $46.50 per month when patients utilize their RPM device daily (99454).Regarding best practices:-
* CPT code 99453 (device setup) can only be claimed once per device, per patient, per month.-
* CPT code 99454 (device use) can be claimed once per patient per month, regardless of the number of devices used. It should be billed in 30-day increments if the patient takes at least 16 daily device readings within that month.
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It's crucial to align claims submissions for these codes since code 99454 can be billed every 30 days, while codes 99457 and 99458 (program time) are billed on a monthly basis. We recommend submitting all RPM-related claims together by calendar month.
About RPM and its billing requirements: RPM is a telehealth program for Medicare Part B beneficiaries. Patients use digital devices to self-collect physiological data, which is then transmitted to their provider for review and management of chronic conditions.
RPM has proven effective, particularly for managing conditions like hypertension, and payors are increasingly investing in similar programs to promote value-based care models.
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Patients covered by Medicare Part B receive 80% coverage for RPM, with many secondary insurances covering the remaining cost.
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RPM services are billed monthly, from the first to the last day of each month.
IStarting in 2024, meeting FDA criteria for designated medical devices is a requirement from CMS for RPM devices. This encompasses various tools such as weight scales, blood pressure monitors, pulse oximeters, glucometers, heart rate monitors, thermometers, and spirometers. We're excited to share that our FDA-approved devices are now accessible.
Let's illustrate with a scenario to grasp how, based on CMS codes, your annual net profit can grow. Healthcare professionals enhance earnings by providing telehealth or extra in-person visits for patients with uncontrolled conditions. Utilizing Remote Patient Monitoring (RPM), physicians can remotely oversee these patients' health, intervening swiftly as required. This proactive strategy not only enhances patient outcomes but also permits physicians to bill for added services provided, be it through telehealth consultations or additional in-person visits.
According to a study in the American Heart Association Hypertension Journal, individuals engaged in a pharmacist-led telemonitoring initiative for hypertension control experienced roughly 50% fewer cardiovascular events than those undergoing standard office-based monitoring. The study encompassed 450 individuals with uncontrolled high blood pressure from 16 clinics in Minnesota. Through random assignment, participants were divided into two groups. Following six months of remote monitoring guided by pharmacists via phone, using at-home monitors, participants maintained lower blood pressure levels over a two-year period compared to the group receiving regular care from their primary physicians. After five years, the remote care group exhibited a 5.3% incidence of heart attacks, strokes, stent placements, or heart failure hospitalizations, in contrast to 10.4% for the routine care group.
$46.50 (99454 monthly x 250 RPM initial patients = $11,625 Monthly reimbursement rate/patient
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$48.13 (99457 monthly x 250 Patients = $12.032 Monthly
reimbursement rate/patient Care Management
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RPM Annual Reimbursement revenue $ 283.890
Est. Annual Care Management Support Serv. - 50.000
250 RPM devices - 40.000
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Annual Net. Profit $198.890
** 2024 CMS BILLING CODES
99453
Initial set-up & patient education on equipment (one-time fee)
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99454
Supply of devices, collection, transmission, and report/summary
of services to the clinician
99457
Remote physiologic monitoring services by clinical staff/MD/QHCP first 20 cumulative minutes of RPM services over a 30-day period
99458
Remote physiologic monitoring services by clinical staff/MD/QHCP for an additional cumulative 20 minutes of RPM services over a
30-day period
99091
Collection and interpretation of data by physician or QHCP,
30 minutes
(Evaluation & Set up - Once time)
(Device supply - Every 30 days)
(Monthly)
(Monthly - Only twice)
(Once a month)