CPT code 99454 is one of four designated codes used to claim billable Medicare reimbursements for RPM or remote patient monitoring services.
Practitioners and healthcare providers can submit a claim via CPT 99454 when they meet specific requirements linked with providing an RPM device and receiving patient measurements transmitted from their RPM device to the provider’s platform or care database.
To be eligible for reimbursement, the healthcare organization needs to have received and recorded 16 days or more of patient data within a 30-day period and show that they have met the requirements and standards set by Medicare.
Billable Events Qualifying for CPT 99454
Remote patient monitoring solutions are increasingly popular for clinicians and medical service providers looking to supervise and monitor large patient groups in a way that is streamlined, convenient, and cost-effective.
Any medical professional can onboard a patient into their RPM program where they feel this is necessary and beneficial, whether the patient has a chronic condition diagnosis or other underlying factors that make them a good candidate for RPM. All eligible Medicare patients receiving RPM are covered, allowing providers to claim CPT 99454.
Devices must be assigned or prescribed by a suitably qualified healthcare physician or practitioner. However, they can delegate or outsource their RPM service provision to a third party if they wish, with the same standards applied to determine whether a service constitutes a billable event.
Patients need to participate in RPM monitoring by taking readings through their assigned device for a minimum of 16 days per 30 days, in compliance with the billing code, which is intended to reimburse practitioners for the costs of supplying and monitoring each device.
Practices and organizations can bill CPT 99454 once per month and per patient, irrespective of whether the patient has multiple RPM devices.
Claiming Medicare Reimbursements for CPT 99454
This CPT code may apply in a variety of circumstances, provided the service relates to the supply of the device or patient monitoring. It can also be used when organizations lease RPM devices.
Patients must consent and acknowledge that they are expecting to participate in an RPM program, either recording their approval verbally or in writing and having this logged within their medical record.
Medicare will reimburse the appropriate rate, depending on the area, when a provider has:
Supplied an RPM device for a patient to take daily readings of their blood pressure, weight, respiratory rate, or blood glucose levels, for example.
Initiated programmed alerts and transmissions to remind patients to take their measurements and ensure these are submitted to the clinician.
Received at least 16 days of readings within a 30-day billing cycle. Measurements do not have to be taken on 16 consecutive days, although the specific frequency of RPM readings should be based on the clinician’s advice.
Reimbursements in 2023 are, on average, $48.93, but this can vary up to around $62 based on the location and geography of the practitioner and patient.
Eligibility Criteria to Claim CPT 99454
Any RPM device should be FDA-recognized and be considered a medical device to ensure the readings taken by the patient are accurate and reliable. Healthcare providers can claim CPT 99454 for a variety of devices, including:
The CPT code covers servicing costs, paid once per month. In contrast, practices and healthcare teams need to claim via CPT 99453 for the set-up of the device and providing patient education, 99457 for 20 minutes of consultative activities per month, and CPT 99458 for additional RPM time over the initial 20 minutes. Read more about these individual CPT codes here:
Provided the patient has submitted the minimum number of readings, CPT 99454 can be billed once every 30 days, contributing to the software behind the RPM device and ensuring it is functioning correctly, regardless of how many parameters are being monitored.
If a patient has more than one device, CPT 99454 remains claimable once per month – at least one device must be used to record patient data and submit these readings to the practitioner or the monitoring team.
Patient Communication and Best Practices
Patient engagement is key, ensuring an RPM program is effective, records accurate and reliable data, and raises an alert when readings are missing, unusual, or indicate a potential need for medical intervention.
Healthcare providers need to ensure their patients understand how their RPM device works, are prepared to take regular readings as instructed, and are comfortable that they know the right times and frequencies with which to record their vital signs.
Onboarding is an important part of the process, both to avoid missing the Medicare standards and being unable to claim reimbursement for partial service delivery and to ensure that physicians are receiving the right data to provide good quality care.
As mentioned, CPT 99453 is the billing code used for the set-up of the patient and for providing information and education on the correct use of the device. This code can be used only once per patient – although it can be reused for the same patient if they complete their care and are then re-enrolled in an RPM service at a later date.
Billing Cycles for CPT 99454 Claims
Once the set-up and configuration process is complete and the patient begins taking their readings, the provider can start using CPT 99454 on a 30-day basis. However, healthcare organizations cannot claim until the patient has provided the minimum number of readings within the billing cycle.
If a patient receives an RPM device, or more than one device, and begins participating but then stops taking their measurements, the provider cannot continue to claim CPT 99454, regardless of whether they have already completed the set-up and claimed CPT 99453.
They also cannot claim CPT 99453 again if a patient requires additional support – the intention is for the initial onboarding process to be thorough and furnish the patient with sufficient understanding to be able to use their RPM device autonomously from there onward.
However, if the patient then engages with the RPM program and resumes their reading transmissions, meeting the 16-day requirement, the medical service provider can continue billing for the claimable value against CPT 99454. Read our full guide on CPT Billing codes here.