Remote physiologic monitoring and clinical data monitoring is a relatively new concept thriving and growing as an essential component for telehealth services. According to global consumer trends, a company called Dynata reported, "Among the 39% of people who consulted a healthcare professional, two-thirds used telemedicine, many of them for the first time (84%)."

Here is a little something you may not be aware of, coming to a state near you; physicians who want to practice in other states can now join what is called the "Interstate Medical Licensure Compact," which is an agreement among participating U.S. states. The rule-making started in 2015, and the bill was introduced to the house in October 2020. The bill requires states and physician licensing boards to promote interstate medical practice and interstate telemedicine. The compact currently includes 30 states. 

Remote Therapeutic Monitoring (RTM)

We can see where this trend is heading, and it is not likely to end soon; for 2022, the AMA released five new codes that will be implemented in January 2022 under a new treatment called Remote Therapeutic Monitoring (RTM).  The AMA has not designated the new RTM codes as evaluation and management E/M codes; therefore, providers who can't bill for Remote Patient Monitoring (RPM) may be able to bill for Remote Therapeutic Monitoring (RTM) as general medicine codes.

Under the new RTM codes, respiratory and musculoskeletal systems have been added as separate systems for monitoring, including setup and education. Remote Therapeutic Monitoring CPT codes include 989X1, 989X2, 989X3, 989X4, and 989X5.

Practice expense only codes (PE) are 989X1, 989X2, and 989X3, and the two professional work CPT codes are 989X4 and 989X5. For more information on the new RTM, codes see the Federal Register here.

The difference between RTM and RPM

Please do not confuse the two; there are some differences; we will discuss RPM in more detail in this article. For example, RTM collects Non-physiologic data related to therapy such as respiratory and musculoskeletal systems, and RPM codes collect physiologic data such as blood pressure, heart rate, vital signs, weight, and blood sugar levels. There is also a difference in who can bill for these services, as RPM codes are E/M codes, and RTM codes are considered general medicine codes.

Remote Patient Monitoring (RPM)

We can expect to see health systems investing more in remote patient monitoring, keeping in mind,  any device used when reporting RPM must meet FDA standards. CMS initially classified RMP for treating and managing chronic illness. However, any provider that can order and bill Medicare for E/M services is eligible to provide RPM services, including physician(s) or non-physician(s).  

There are several things to consider when providing remote Patient Monitoring (RPM). Initially, be sure you are aware of the rules released in 2021 for remote patient monitoring. Since RPM is relatively new, there have been a few changes since 2019.

RPM Codes
One of the first codes used to report this type of monitoring was reported with 99091. While this code is still in effect, there are more specific codes. Do not report 99091 with 99457. In addition, to report 72-hour glucose monitoring, use 95250. 

In 2019 new codes 99453, 99454, 99457, and 99458 were added with very little instruction. Most of the confusion has been clarified in 2021; this article will address the highlights.   

The RPM process begins with two practice expense (PE) only codes, CPT codes 99453 and 99454. As PE only codes, they are valued to include clinical staff time, supplies, and equipment, including the medical device for the typical case of remote monitoring. Payers may require modifier 26 to be appended to these CPT codes to report the professional component and interpretation of monitoring results. This is where the practitioner includes time spent reviewing and analyzing the patient's RPM data and determining how to change the care management accordingly, qualifying the professional care component to be reported separately by appending modifier 26. 

• 99453 represents: clinical staff time
• 99454 represents: the medical device or devices supplied to the patient and the programming of the medical device for repeated monitoring 

To correctly bill 99453 and 99454

• 99457 is to be used as the add-on code for 99453
• 99453 can only be billed once per episode of care
• Do not report 99453 for monitoring of fewer than 16 days of a 30 day period

99453 can only be billed once per episode of care. According to the AMA, "An episode of care is defined as beginning when the remote monitoring physiologic service is initiated and ends with attainment of targeted treatment goals."

To correctly bill 99457 and 99458

• 99458 is used as the add-on code for 99457
• Services less than 20 minutes are not reported with 99458
• 99473 and 99474 cannot be reported with 99457 in the same month
• 99457 should not be reported with 93264 or 99091

The definition has been revised on 99457 and 99458, adding 20 minutes of time associated with 99457 and 99458. These include care management services and synchronous, real-time interactions. The changes indicates that time is no longer the only activity. It is yet to be determined what the rest of the time is to be reported as.  

The current default requirement now states, "The medically necessary services associated with all the medical devices for a single patient can be billed … when at least 16 days of data have been collected." There are exceptions; however, those include anomalies identified under the PHE waiver as acceptable for the 2-day requirement.

RPM codes are in the Evaluation and Management (E/M) services section under care management services. Remember, only one time-based code is allowed per day unless the conditions are met for the use of modifier -25, which may be required for specific payers.  

According to CPT guidelines, "Do not count any time on a day when the physician or other qualified health care professional reports an E/M service." Be sure to see the CPT coding guidance and carefully read the descriptors of the codes to determine other codes that cannot be billed on the same day. For example, 99453, 99473, and 99474 all include blood pressure monitoring.

AMA guidelines state the following services should not be billed with RTM (timed) codes.

Other Considerations

• CPT codes 99457 and 99458 can be furnished by clinical staff under the general supervision of the physician or NPP. 
• CMS will only pay for one practitioner using 99423 and 99454 during a 30-day period.
• Interactive communication should total at least 20 minutes of time with the patient over the course of a calendar month for CPT code 99457 to be reported.
• "Interactive communication" for purposes of CPT codes 99457 and the add-on code 99458 involves, at a minimum, a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.

COVID Exceptions

In the 2021 Proposed Rule, CMS clarified that RPM services are limited to "established patients." However, to reduce the risk of exposure for COVID-19 and not limit healthcare during this time, on an interim basis for the duration of the PHE for COVID-19, RPM services can be furnished to new patients, as well as established patients. When the PHE for COVID-19 ends, it will again be required that RPM services be provided only to an established patient.

Who can provide RPM Services?

In the 2021 Proposed Rule, CMS proposed to allow auxiliary personnel, in addition to clinical staff, to furnish services described by CPT codes 99453 and 99454 under the general supervision of the billing physician or practitioner. Auxiliary personnel includes other individuals who are not clinical staff but are employees or leased or contracted employees.  As noted in the 2021 Proposed Rule, CMS supported its proposal under the idea that "The CPT code descriptors do not specify that clinical staff must perform RPM services." 

RPM services are not considered to be diagnostic tests. Including the order of a physician or NPP, it is not appropriate for the services to be provided or billed by an independent diagnostic testing facility.