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RPM Billing Explained: Billing for CPT Codes 99453, 99454, 99457 & 99458

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What is a CPT Code?

Current Procedural Terminology (CPT codes) are numbers assigned to every task and service a provider administers to a patient, including medical, surgical, and diagnostic services. Insurers use these codes to determine the amount of reimbursement that a practitioner will receive from an insurer for that service.

What is a reimbursement? 

Healthcare reimbursement describes the payment that your hospital, doctor, diagnostic facility, or other healthcare providers receive for giving you a medical service.

Asynchronous Care

Asynchronous care is “Term describing store-and-forward transmission of medical images and/ or data because the data transfer takes place over a period of time, and typically in separate time frames. The transmission typically does not take place simultaneously,” according to americantelemed.org. Remote Patient Monitoring (RPM) is a form of asynchronous care that some patients rely on for managing and bettering their conditions. 

Remote Patient Monitoring (RPM)

Remote patient monitoring (RPM) uses asynchronous care by allowing patients to submit vital health metrics directly to their provider team outside of the healthcare setting.

The main CPT Codes that are used for RPM are 99453, 99454, 99457, 99458.

 

RPM CPT Code

The Centers for Medicare & Medicaid Services (CMS) have established CPT codes for remote patient monitoring (RPM). RPM tracks patient vitals outside of the healthcare setting to allow providers to intervene and improve health outcomes.

RPM CPT Code: 99453

RPM CPT Code: 99453 handles remote monitoring of physiologic parameters, including weight, blood pressure, pulse oximetry, respiratory flow rate. The code represents the initial; set-up and patient education on the use of equipment. This is one time billing code that is used at initial enrollment. The devices recommended must be ordered by a physician or qualified healthcare professional (QHP). CPT Code: 99453 averages about $19.00 when billable. 

RPM CPT Code: 99454

RPM CPT Code: 99454 is used for the monthly remote monitoring of the physiological parameters and covers the supply and provisioning of the device that the patient is using. Again, the device must be ordered by a physician or QHP. CPT Code: 99454 is billable every 30 days and covers the cost of leasing the device for at home patient use. In 2021, CMS provided clarification that this code requires at least 16 days of device readings that need to be submitted by the patient within the 30-day period. These recordings from the patient will be remotely sent to their care team. The standard reimbursement for CPT Code: 99454 regardless of the cost of devices, is $62.00 for technologies provided under this code. 

RPM CPT Code: 99457

RPM CPT Code: 99454 is used for the care management of RPM.It is the monthly billing code for RPM patients. It requires 20 minutes of interactive virtual care during the calendar month that a qualified healthcare provider or care manager gives to the patient. This code is billable once a month regardless of the RPM patient’s conditions. On average the reimbursement for this code is $52.00. 

RPM CPT Code: 99458

RPM CPT Code: 99458 is also a part of the interactive virtual care during the calendar month. However, this code is for additional time spent with the patient.  Healthcare organizations can additionally bill in 20 minute increments using this code after they meet the requirements for code 99457.  For example, if a patient gets 40 minutes of virtual care covered by RPM, this code will be used to bill for the incremental 20 minutes. On average, the reimbursement for the code will be $42.00. 

 

The reimbursement billing is different for each CPT code under the RPM umbrella, and can differ depending on the provider of care. The national average for each RPM CPT code is as followed:

RPM CPT Code: 99453: $19.00

RPM CPT Code: 99454: $62.00

RPM CPT Code: 99457: $52.00

RPM CPT Code: 99458: $42.00

In the first month of RPM if a patient has initial setup, submits at least 16 days of readings, receives first 20 minutes of care the monthly reimbursement average will be $144.  Average reimbursement would increase $43 for each additional 20 minutes of care provided.

After the first month of care, if a patient submits at least 16 days of readings and receives the initial 20 minutes of care, the monthly reimbursement average will be $123.  Average reimbursement would increase $43 for each additional 20 minutes of care provided.

Sources:

https://www.foley.com/en/insights/publications/2020/12/2021-remote-patient-monitoring-cms-final-rule#:~:text=RPM%20involves%20the%20collection%20and,99454%2C%2099457%2C%20and%2099458
http://www.pyapc.com/wp-content/uploads/2019/10/Providing-and-Billing-Medicare-for-Remote-Patient-Monitoring-PYA.pdf
https://www.healthrecoverysolutions.com/hubfs/Reimbursement%20Webinar/2020%20CPT%20Billing%20Guide.pdf
https://timedochealth.com/remote-patient-monitoring/
https://validic.com/your-guide-to-reimbursement-for-remote-patient-monitoring/#:~:text=CPT%20Code%2099453%20allows%20for,the%2030%2Dday%20billing%20period
https://www.americantelemed.org/resource/why-telemedicine/

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