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This guide clarifies billing for Remote Physiological Monitoring (RPM - aka Remote Patient Monitoring) utilizing the calendar year 2021 Physician Fee Schedule Final Rule. The RPM services discussed focus on the following CPT codes: 99453, 99454, 99457, and 99458.

Reimbursement ranges for RPM from region to region. Check with your local MAC payor rep for reimbursements in your area. The table below highlights the national averages reimbursed by the Centers for Medicare and Medicaid Services (CMS) and some best practices for devices, program engagement, and patient monitoring.

STEP 1

Start by onboarding your RPM patients correctly.

RPM CPT Code 99453

What it covers?

• Start every RPM patient with this code. This is a one-time expense that reimburses you for the initial set-up, patient program onboarding, equipment education. The device must be FDA approved and automatically send readings to a remote clinician.

• TupeloLife provides cellular based devices, so there is no need for expensive tablets and worrying about internet connectivity.  They work straight out of the box!

CPT Code 99453 Nuances

How to bill for it?

• Remember, this is a one-time code, and it is billed alongside 99454. This means that you can bill for this code once your patient achieves 16 days of readings within a 30-day period. 

What you’ll need?

• To be reimbursed, be sure your RPM telehealth service provider can deliver a billing report that ties this code with the initial set of 16 days for code 99454.

• TupeloLife automatically provides appropriate billing reports that make filing for reimbursement as simple as possible. 

Follow up with RPM CPT Code 99454

What it covers?

• This code covers the cost of supplying devices, the platform, and data transmission. All devices provided to the patient must be a home-use device per FDA guidelines and not a reimbursable Durable Medical Equipment (DME) device.

• TupeloLife devices meet FDA requirements, include data transmission capabilities using 4G network, delivering data safely and securely to your EHR.  

CPT Code 99454 Nuances

How to bill for it?

• This code requires 16 days of transmitted patient data within a 30-day period. You can only bill this code once per month, not per the number of devices that the patient has been given.

• Our algorithms will keep track of patient dates, data and timeframes to accurately bill for services. 

What you’ll need?

• To maximize your reimbursement, be sure your RPM vendor’s software is able to track the reading transmission days in accordance to a rolling 30-day period per patient and not against a calendar month.  

• Furthermore, be sure to receive invoices for the monthly services related to the devices to avoid violating federal laws such as gifting devices to patients.

• Billing with TupeloLife is simple. Each month you will receive billing reports to successfully submit for payment per each code. One report covers the devices, software and onboarding, while the other report covers the patient monitoring minutes.  

STEP 2

Follow up with each patient and start your daily monitoring and management.

RPM CPT Code 99457 and 99458

What it covers?

• These codes cover the clinical staff time to review and analyze patient data and patient communications provided by the healthcare provider and the clinical staff.  

• Physicians and qualified healthcare professionals can provide RPM. Clinical staff can manage RPM under the general supervision of the billing provider.

• TupeloLife provides a registered nurse-led Care Team to help busy practices focus on the patients that need their immediate attention.  We utilize Care Plans powered by the American Heart Association to engage patients on a daily basis, educate them on their condition, and help coach them on their journey to better health.

CPT Code 99457 and 99458 Nuances

How to bill for it?

• CMS mandates that CPT code 99457 covers at least 20 minutes interactive communication during a calendar month. This communication can be over the phone as well as through connected technologies. You can bill for this code without the 16-day readings.  

• CPT Code 99458 covers additional staff time for every additional 20-minute increments per calendar month.

What you’ll need?

• Be sure your RPM Telehealth vendor provides you with itemized time for each patient on service outlining the number of minutes within a calendar month, and the rolling 30-day to submit your claim for CPT Code 99454.  

• Capturing proper time spent and the proper billing information is key for reimbursement. Be sure to also get outcome reports in order to demonstrate how effective your program is.

STEP 3

Submit your claims 

Submit your claims report based on billing reports that group CPT codes 99453 and 99454 to cover ongoing device and software usage and a second report based on 99457 and 99458 that outline the time spent managing patients each calendar month. RPM can be provided to any patient with a chronic condition, where a prescribing provider believes home data capture, ongoing evaluations, and education will help manage the patient’s conditions and improve health outcomes. Although CMS has provided specific guidelines on the condition types, medical necessity will require proper ICD-10 coding for the condition being monitored. 

Frequently Asked Questions

COVID-19 Public Health Emergency

• Post PHE there must be an established patient-physician relationship 

• Copays are also waived during the PHE.

How can I bill for these codes?

• Physicians or qualified health practitioners that can bill for E&M visits can also bill for RPM.

Can my clinic contract services to manage my RPM patients?

• Monitoring of physiologic data is billed “incident to” under the general supervision of the billing physician. The physician does not need to be onsite when the patient services are provided by the staff.

BETTER RPM STARTS HERE.

Optimize your RPM program with a trusted advisor. Contact us for more information.

Call us at (469) 914-0044 or email info@tupelolife.com.

About TupeloLife Digital Therapeutics

TupeloLife Digital Therapeutics offers a value-based RPM program. This means our RPM program is designed to meet reimbursement criteria, while guiding patients to meet value-based HEDIS metrics using evidence-based care plans powered by the American Heart Association®.