New codes from the AMA could mean higher RPM reimbursement by 2025
Today, most remote patient monitoring services are billed under four current procedure terminology codes. These codes can be split into two categories to help understand their usage. There are two RPM device monitoring codes – 99453 and 99454 – and two timed RPM management service codes – 99457 and 99458.
CPT 99453 covers the time it takes to enroll patients in RPM and get them set up on their devices. This amount can only be billed once per patient registration. CPT 99454 is the monthly RPM code associated with monitoring and evaluating patient data sent from the connected device. Today, providers can only bill for this code within a certain 30-day period for patients who report at least 16 calendar days of device readings.
CPT 99457 is for spending a minimum of 20 minutes of clinical time providing care management services related to patient measurements and their treatment plan. Finally, CPT 99458 is used when clinical staff time is 40 minutes, at which point a second 99458 can be billed for 60 minutes. These have been the four most common general RPM codes for a few years now.
Medicare was the first to cover RPM. Currently it is also covered in some form by approx 32 state Medicaid programs. Numerous commercial payers also cover RPM, sometimes within their telehealth coverage policies.
But things can change, and for the better. Providers may soon be able to invoice much more remote patient monitoring. The proposed changes are currently on the public agenda for the American Medical Association’s CPT Editorial Panel meeting in May. There are three particularly important changes that AMA is considering for RPM that will be discussed at the meeting.
Daniel Tashnek is the founder of Prevounce, which offers software, connected devices and care management services aimed at making preventive chronic care and remote patient monitoring programs easy to deploy and scale. He is an expert in RPM coding. We sat down with him to discuss the proposed coding changes.
Q. Summarize the American Medical Association’s proposed changes to RPM coding.
A. The first – and this would be a very big deal – is the addition of a code that would cover two to fifteen calendar days of data collected and transmitted. CPT 99454, the only current generic CPT code for RPM devices, can only be used if a provider has received and recorded 16 or more days of patient data within a 30-day period.
The addition of a new code would allow providers to code for 30-day periods in which fewer than 16 but at least two measurements are recorded.
The second notable change being considered is a revision to CPT 99457 to include 11 to 20 minutes of RPM care management time. 99457 currently requires a minimum of 20 minutes of logged care management time.
Revising 99457 would reduce the amount of time it takes a provider’s clinical staff to provide RPM monitoring and care management time for a patient during the month to report the code.
The third is a revision to CPT 99458, covering every additional 10 minutes of interactive communications. 99458 currently requires a minimum of 20 additional minutes of interactive communication. Revising 99458 would reduce the amount of additional time clinical staff must spend reporting the code.
Q. What is the reason for the changes?
A. The AMA has not yet provided a public argument as to why it is considering these substantial changes. We’ll learn more about the rationale at the CPT editorial meeting in May. From my personal perspective, the proposed changes make sense for several reasons.
In developing the general remote patient monitoring codes, the AMA had to strike a balance between limiting billing for de minimis or unreasonable monitoring programs while allowing room for innovation as new monitoring programs were created and studied.
The 99454 RPM code was the first economically viable remote monitoring code that did not explicitly specify a device type. Because the code was device agnostic, the AMA had to rethink how it had structured its criteria in the past to ensure incentives were in place to design and implement useful monitoring programs. As a compromise, they settled on a requirement of 16 measurement days per 30-day period, and it was clear that they would keep an eye on whether they found the right balance.
Since that time, there has been a growing body of clinical research showing that well-designed RPM programs can improve patient outcomes while reducing healthcare costs. Many clinical practitioners of RPM have submitted comments over the years that the 16 measurement day requirement arbitrarily limits many useful monitoring programs where fewer measurements are clinically adequate.
The same goes for spending 11 to 19 minutes on care management under 99457. Currently, what happens when a provider spends 15 minutes educating and guiding a patient in an RPM program? The provider provides a valuable service to the patient, but is not currently eligible for reimbursement.
This will likely deter providers from continuing to support this patient and hinder the growth of an RPM program.
The changes being considered generally appear intended to promote higher RPM adoption and greater program flexibility by lowering the barrier to entry for both patients and providers. By rebalancing the codes based on what we’ve learned since their initial release, we can better ensure that providers are paid appropriately for their time and services, while still guarding against frivolous or unreasonable monitoring programs .
Q. What is the potential impact on healthcare providers with remote patient monitoring programs?
A. The AMA’s public agenda only gives us a summary of the changes being considered, but from what we can tell, the changes as written could significantly expand the scope of both existing and new RPM programs. Because the adjustments only expand the allowable criteria, existing RPM programs could continue to do exactly what they are doing now without much change.
If the AMA approves the contemplated changes and Medicare follows suit, which is usually the case, providers making those changes and expanding their RPM programs to meet the new codes will reap the most benefits for their patients and their clinics.
The same goes for private payers and health plans adjusting their coding rules to reflect the AMA changes. Providers must ensure that their RPM software and service providers remain up to date and that their systems reflect the changes to maintain compliant coding and billing.
Once the dust clears, we are left with a wider range of conditions and patients that can be treated with RPM. Some specific modalities that can be legitimately performed with a lighter patient touch will become feasible. I expect that medical RPM weight loss programs will become more common, for example.
It is also worth noting that Medicare is not necessarily required to update its coding rules to reflect the AMA’s CPT code lines. However, the federal agency often does this. Private payers and health plans can choose not to update to the new code sets, but these rarely deviate from the AMA rules.
If AMA makes these changes to the RPM codes, coverage changes will most likely take effect in 2025 or later.
Q: What are some insights you gain from the direction the AMA is considering?
A. While this expansion of RPM codes is currently only being considered by AMA, I believe we see the association further recognizing the significant value of remote care management services such as RPM and a desire to explore how this can further enable providers motivate them to launch programs and help those with existing programs expand them to include more patients.
While those of us in the industry hear rumors about overuse and vendors of fly-by-night monitoring, the AMA and Medicare clearly see the value of well-designed remote monitoring programs. I believe the consideration of these changes is part of an ongoing effort to expand the parts of RPM that work, as we begin to campaign against those who circumvent or abuse the codes.
From a macro perspective, we are facing a growing shortage of physicians and other clinical staff positions. Care management services like RPM help meet patients’ ongoing needs while reducing the number of in-person office visits. RPM also helps steer patients in the right direction for their care, which can help reduce the number of unnecessary hospital and office visits.
There is also an increased focus on rural Americans, who face numerous health disparities compared to those living in urban areas. Rural populations experience a higher prevalence of chronic conditions, in addition to higher barriers to receiving care.
AMA has worked to address these challenges through several initiatives, and the expansion of care management services can undoubtedly play a role in helping to bridge the gap in care. Medicare just expanded rural RPM programs by allowing separate RPM reimbursements to federally qualified health centers and rural health clinics.
The AMA’s expansion of RPM codes would only help encourage further adoption, which, if done properly, would be extremely effective in helping reduce rural disparities.
I am hopeful that AMA will follow through with the changes it is considering. Assuming this happens, I hope Medicare and other payers will do so as well, while setting reimbursement rates at amounts that encourage even greater adoption and growth.
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