RPM caution: Remote monitoring can boost care quality and revenue, but watch out for coding and documentation regs that may curb some enthusiasm

Jennifer SwindleCoding

Much attention has been paid to the explosion of telehealth technology and services during the pandemic. It is viewed as one of the bright spots in an otherwise bleak year in the business of healthcare. Mostly, the action has been in telehealth visits – doctors discussing care with patients over whatever communication devices they have, including phones. Most observers think an expansion of televisits is here to stay, but it is going to be more regulated post pandemic.

Another aspect of virtual care, remote patient monitoring (RPM), may turn out to have a more significant long-term impact on patient care and revenue than televisits. RPM, also called remote physiological monitoring, is the collection and/or analysis of data to help manage a treatment plan related to a chronic and/or acute health illness. It uses digital technologies to monitor, capture, and transmit vitals such as blood pressure, weight, heart rate, and blood sugar levels from patients to providers for assessment, recommendations and instructions.

Revenue enhancer
Thanks to an overhaul of CPT codes for 2020, RPM became one of the more lucrative Medicare care management programs even before the pandemic. The vast majority of RPM services are now billed under four CPT codes: 99453, 99454, 99457 and 99458. There is a small payment for initial patient enrollment into an RPM program, and then a monthly base payment for management of the device and patient readings. Finally, there is an optional service for each 20 minutes of care management – which can be provided by clinical staff – up to 60 minutes total. When added together, each RPM patient can earn a practice up to around $210 per month, according to McKinsey & Co. projections.

CMS has proposed further changes to these services for 2021, so when the current public health emergency ends, it is important to understand that you need to meet new coding requirements.
As with all services, medical necessity is crucial for coverage of RPM. It is also required that the provider obtain permission from the patient prior to providing RPM services; this patient consent must be documented in the medical record. The consent can be obtained on the same date as RPM services are provided.

The proposed rule for 2021 does clarify that RPM services can be provided to patients with acute conditions; chronic conditions are not required.

Who can provide RPM
Although the public health emergency waiver allows RPM for new patients, this will not be true once the emergency has ended, so only established patients can be monitored. RPM must be ordered and billed by the physician and/or other qualified healthcare professional (a provider with the ability to bill Evaluation & Management services, such as physician assistant, nurse practitioner, clinical nurse specialist; not ancillary staff).
There is some difference in what type of provider may furnish the service, as the 99091 can only be provided by the physician or other qualified healthcare professional; however, services for codes 99457-99458 can be provided by ancillary clinical staff as well, under the general supervision of the physician. The proposed rule also allows services for codes 99453-99454 to be provided by supervised clinical staff as well. RPM is not considered a diagnostic service, so it cannot be provided by an independent diagnostic testing facility.

One big change, which is at variance from most guidance on time-based codes, is the time for interactive communication. Historically, CMS has been clear that the time-based requirements consist of a combination of interactive communication, monitoring and management of the patient’s care plan, which is consistent with the code descriptors. In the proposed policy clarification, CMS has taken a different approach to the time component and is only considering the “interactive communication time.”
CMS stated that for purposes of CPT codes 99457 and 99458, interactive communication must total at least 20 minutes over the course of the calendar month for 99457; an additional 20 minutes of interactive communication is needed to report 99458. The interactive communication must have a real-time, synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission. The documentation throughout the month must support the time spent to achieve the right coding, but also must separately capture how much of the time was interactive communication, based on this requirement.

Remote patient monitoring codes and descriptions, 2021 proposed

CPT CodeDescription
99091Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring), digitally stored and/or transmitted by the patient and/or caregiver to the physician or other healthcare professional qualified by education, training, licensure/ regulation (when applicable), requiring a minimum of 30 minutes of time each 30 days.
99453Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial setup and patient education on use of equipment.
99454Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
99457Remote physiologic monitoring treatment management services. Clinical staff/
physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes.
99458Remote physiologic monitoring treatment management services, clinical staff/physician/
other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes.

This CMS’ interpretation would appear to mean that the practitioner and clinical staff must use the RPM, analyze the data, assess it, update the care plan accordingly, and also spend at least 20 minutes talking on the phone or via video with each monitored patient each month. For example, if a doctor spent 50 minutes overall during the month in providing RPM services, but only 17 minutes of that time was actually interactive communication, RPM services could not be reported. If you have been capturing the total time of all services to arrive at your time and codes, this would certainly have a negative impact on how to code, as the time of monitoring and updating the treatment plan would not support the time component of the service. It is anticipated that this change will be one of the most challenged during the comment period.

It also should be noted that under the rule, CPT codes 99453-99454 could not be reported more than once during a 30-day period. Also, monitoring must occur over at least 16 days to be reported. The proposed rule also seems to suggest that 99457-99458 cannot be billed until after the initial 30-day period of monitoring.

All eyes will be on the final rule. Remote patient monitoring is a way for providers to use clinical staff to remotely monitor patients and improve revenue, but complying with these new regulations will not be as easy as it may have appeared during the pandemic.