The Difference between Remote Patient Monitoring (RPM) CBT codes and realizing better care and reimbursements

Telehealth,Remote Patient Monitoring (RPM), and Chronic Care Management (CCM) are keyelements to redefining the delivery of care. Fundamentally, these services, via a common unified experience, demandgreater patient engagement.  

As for RPM, there are four CPT codes:
  • 99453: Remote monitoring of physiologicparameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flowrate), initial; set-up and patient education on use of equipment)
  • 99454: Remote monitoring of physiologicparameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flowrate), initial; device(s) supply with daily recording(s) or programmed alert(s)transmission, each 30 days)
  • 99457: Remote physiologic monitoringtreatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communicationwith the patient/caregiver
  • 99458 (2 units): Remote physiologicmonitoring treatment management services, clinical staff/physician/otherqualified health care professional time in a calendar month requiringinteractive communication with the patient/caregiver during the month; eachadditional 20 minutes (list separately in addition to code for primaryprocedure)

Note: Technically there is a 5th CPT, 99091, however, we won’t cover this code in this post.

The myth surrounding RPM is: “Do nothing, make millions – adopt RPM; your revenue andprofitability problems are solved; physicians can get off the hamster wheel andrelax.”  Sadly, this dramatization is toooften the common interpretation of the general message from RPM vendors.  While adopting RPM has great potential – allare not equal.  When evaluating a virtualcare platform and services partner, consider using the following evaluationcriteria:  

  • Regarding the 16-day measure (99454) –what is the service partner’s average monthly compliance across their patientpopulations?  95% compliance is a solidmeasure.
  • One should ask for a sample applicationof their billing practices to ensure there are no charges when reimbursementcriteria for the 16-day measure (99454) and/or care management services (99457and 99458) is not achieved.   Mitigate one’sfinancial risk by ensuring billing is based solely on the achievementreimbursement criteria.
  • Understand their patient engagementstrategy as well as their past performance. Example:
  • CareManagement performance: How many minutes, on average, per patient per month, have been  documented, to support 99457/99458 reimbursements? A solid measurewould be 40 minutes.
  • PatientSatisfaction: knowing their Net Promotor Score (NPS) is a solid barometer.
  • Ensurealternative access points: web browser and smartphone app.
  • Explore scalability options to ensurefuture growth.  Does the proposed virtualcare platform also support telehealth, CCM, RTM and other virtual carefeatures/functions?

The Realities of an RPM Program:

  • Not all health plans are the same, aspart of one’s roll-out, have discussions with each health plan regarding RPMadoption efforts.

  • Coding for RPM reimbursements is going to be new; present to each health plan sampleclaims to ensure accuracy.
  • There are situations, when theprovider or designee will be disrupted during the day to address care escalation.
  • Co-pay for certain plans may berequired – be sure patients are aware of this requirement.

To maximize theoverall success of the RPM initiative, be sure to ask questions; however, one shouldpause if the lead story is centered only on the financial carrot rather than coupledwith clinical outcomes.