Imagine spending precious time and money setting up a remote patient monitoring program at your practice only to realize it’s too costly to maintain. If you’re on the fence about setting up such a program, you can avoid that worst-case scenario. We’ll break down the ins and outs of remote patient monitoring reimbursement so you can feel confident that it makes financial sense for you.
Remote patient monitoring is a healthcare delivery model that uses tech to monitor patients’ health outside of your clinic or practice. Put simply, remote patient monitoring uses electronically transmitted patient health data to assess and monitor patient vitals remotely.
Practices that can master the reimbursement component shouldn’t hesitate to reap the many benefits of a remote patient monitoring program. For you, it’s a chance to get a more complete look at your patient’s overall condition while boosting your marketing and patient retention efforts. For patients, remote monitoring helps them establish a chronic care management routine and gives them more control over their health.
Luckily for you, we’re going to break down the four more important things to know about remote patient monitoring reimbursement.
Here’s what we’ll cover:
Understand how remote patient monitoring coverage works
Remote patient monitoring reimbursement is pretty simple from a coverage perspective because it’s covered by Medicare as well 27 state Medicaid services. Additionally, many commercial insurance providers cover remote monitoring using their telehealth coverage policies. In fact, the number of commercial insurance providers who offer remote patient monitoring coverage has increased due to the COVID-19 pandemic.
When planning a remote patient monitoring program, it’s important to take stock of your practice’s patient population to determine whether your practice is a good candidate to make a continual profit. For instance, if you have a lot of Medicaid and Medicare patients with chronic conditions (heart disease, high blood pressure, diabetes, etc.), you probably have enough patients to set up a remote patient monitoring program right away.
On the other hand, if you’re a smaller independent physician who mostly sees privately insured patients who don’t experience chronic conditions, you might not be well set-up to start a remote patient monitoring program today.
Additionally, remote patient monitoring should be one of your first thoughts for patients with chronic conditions who prefer telehealth, telemedicine, or at-home treatment who are insured or qualify for Medicare or (in some cases) Medicaid services because they are covered and your reimbursement process will be simple.
Key considerations: If you want to start a remote patient monitoring program, it’s important to have a firm grasp on your patient population. Running patient surveys to gauge interest is a great place to start once you know if your patient population can support a robust and profitable remote patient monitoring program.
Know which CPT codes are crucial for remote patient monitoring reimbursement
If you want to be reimbursed, you need to know which Current Procedural Terminology (CPT) codes are important for remote patient monitoring services.
The five primary Medicare RPM codes are CPT codes: 99453, 99454, 99457, 99458, and 99091. Remote patient monitoring codes are considered evaluation and management (E/M) services and can be ordered and billed only by a healthcare provider or non-physician provider who are eligible to bill Medicare E/M services.
Most remote patient monitoring services will be billed under four codes that are split into two categories: service codes and timed remote patient monitoring management codes.
Remote patient monitoring service codes
CPT code 99453 and 99454 are practice expense only codes specifically related to device set-up and education and are valued to cover clinical staff time, supplies, and equipment, including the medical device for remote monitoring.
Remote patient monitoring management codes
- CPT code 99457 reimburses medical professionals and healthcare organizations for their time spent performing duties related to interpreting remote monitoring physiologic data such as medical decision-making to assess patient stability, communication with patients either in person or via telehealth service, and oversight of the management and coordination of service.
- CPT code 99458 is an add-on code to 99457 for each additional 20 minutes of remote physiologic monitoring treatment management service provided in a 30-day calendar month.
- CPT code 99091 is for the collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional. It can also be billed monthly but has more requirements than CPT codes 99457 and 99458.
Key considerations: Practices risk financial losses if they fail to code care correctly with the Center for Medicaid and Medicare Services (CMS), so if your care organization is thinking about adopting a RPM service, you need to know what CPT codes to worry about and how they affect your practice.
Calculate how much Medicare pays per CPT code assigned to remote patient monitoring
It’s important to understand how much you can expect to get paid per patient for your remote monitoring services.
Here’s how remote patient monitoring reimbursement breaks down using average Medicare reimbursement:
- Using CPT code 99453, Medicare pays a one-time payment of $18.48 for initial patient enrollment into the program. This includes the setup of the remote patient monitoring device, the delivery of the device, patient education, and receiving initial remote patient monitoring services.
- Using CPT code 99454, Medicare provides a base monthly payment of $55.77 for continuously monitoring patient data transmitted from the device (like blood pressure or blood sugar levels) as well as ongoing management of the device.
- Using CPT code 99457, Medicare provides a monthly payment of $50.18 for 20 minutes of communication between the patient and caregiver or practitioner specifically pertaining to the data transmitted by the device.
- Using CPT code 99458, Medicare provides an additional $40.84 if the time spent exceeds 20 minutes but is less than 40 minutes. If you spend more than 40 minutes per month, Medicare will provide an additional $40.84 dollars. There is no additional reimbursement after 40 minutes.
- Using CPT code 99091, Medicare provides a monthly payment of $56.41 for collecting and interpreting the transmitted and stored physiologic data provided by the remote patient monitoring device. The amount of time spent interpreting and analyzing must be at least 30 minutes to qualify for reimbursement.
A single remote patient monitoring patient will earn your healthcare organization $2,928.48 per year, assuming you get reimbursed the maximum reimbursement per month.
If your practice enrolls 50 patients into a remote monitoring program, and, assuming you get reimbursed for the maximum amount you can each month for each payment, you’d earn $147,348 in annual Medicare remote patient monitoring reimbursement. Even after you factor in the cost of remote patient monitoring software, you’d still be yielding a significant and consistent amount of revenue.
Key considerations: Realistically, your care organization will likely only meet the initial 20 minutes for reimbursement, and you also might not consistently meet CPT code 99091 each month, so it’s important to factor in how much time you can feasibly devote to each patient enrolled in the program when calculating potential revenue.
Understand which CMS guidelines pertain to remote patient monitoring reimbursement
You must understand the CMS guidelines for remote patient monitoring to reduce the likelihood that your claims get denied.
In order to even qualify for reimbursement, CMS expects your practice to follow these remote patient monitoring requirements:
- Charge Medicare Part B patients a 20% copayment.
- Receive verbal or written consent from a patient to receive remote patient monitoring services.
- Ensure the remote patient monitoring services are ordered by a physician or other “qualified healthcare professional” (nurse practitioner, certified nurse specialist, or physician assistant).
- Monitor patients for at least 16 days per billing period.
- Verify physiologic data can be wirelessly synced for evaluation.
- Confirm each remote patient monitoring device meets the U.S. Food and Drug Administration’s definition of a medical device.
- Ensure the remote patient monitoring device can digitally and automatically upload patient physiologic data which cannot be self-recorded or self-reported by the patient.
Key considerations: Meeting these requirements should be relatively easy for any healthcare organization, but it’s important to have a complete understanding of them in order to avoid claims denials and scrutiny.
Remote patient monitoring allows practices to provide an important service while also being reimbursed
Remote patient monitoring is swiftly becoming more important than ever for patient care because of the shifting necessity and popularity of telehealth, telemedicine, and virtual care. It’s also an aspect of value-based care, which is a pricing model that incentivizes your practice based on the quality of services you provide to patients.
Adopting a remote patient monitoring program will help your healthcare organization get a more complete look at your patient’s overall condition, give your patients more control over their health, and will make your practice more marketable while helping retain patients.
If you’ve never thought about implementing a full-fledged remote patient monitoring program, the additional annual revenue numbers above might have pushed you over the edge. We’ve got plenty of guides and resources to help you get your remote patient monitoring program up and running:
Methodology
Software Advice conducted this survey in August 2021 among 485 respondents to learn more about patient preferences and expectations for personal wearable device data and how it should be used by their healthcare providers. Respondents were screened for their location (United States) and how they kept track of their personal health history. For more information, see our methodologies page.
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