Remote Patient Monitoring (RPM) payment claims are primarily covered by the Medicare reimbursement system. From July 2020 onward, a great deal of state Medicaid programs also incorporate RPM services.
Healthcare providers are increasingly offering RPM services to manage and support wider patient demographics without stretching resources and to supplement organizational revenues to sustain high-quality levels of care for patients who find conventional care models inaccessible.
In the advancing healthcare climate, many private insurance payers and commercial coverage providers are also covering payments for RPM services in response to the demand for virtual healthcare services that arose and has been sustained since the COVID-19 pandemic.
How Do Healthcare Providers Claim Payment for RPM Services?
The main method of attracting revenues in line with RPM programs is through the Medicare system, with a range of revamped CPT codes introduced in 2020 that directly address the need for wider implementation of RPM programs.
Medicare provides payments depending on multiple variables such as location and based on the service delivery codes claimed, which, on average, provide reimbursements as follows:
Note that some CPT codes linked with RPM programs are claimable once per patient, and others are claimable once every 30 days as part of an ongoing virtual healthcare program.
On average, healthcare providers claim around $120 per month per RPM program and patient, with a maximum claimable value extending upward to approximately $210 depending on the patient’s care needs, conditions, and the complexity of care management and interactions.
A standard-sized healthcare organization with 50 RPM patients enrolled in a program claiming minimum reimbursements could supplement their revenues by around $72,000 per annum without removing resources from circulation while delivering high-quality, personalized, and accessible care to all enrolled patients.
How Does RPM CPT Coding Link to Reimbursement Rates?
We’ve summarized the primary CPT codes used in RPM service delivery. Most ongoing services will be billed through the two service codes – CPT 99453 and CPT 99454 and the management codes – CPT 99457 and CPT 99458.
These are described above, but the service codes relate to the remote monitoring of physiologic data and measurements, such as blood pressure, respiratory flow, weight, and blood glucose levels.
While CPT 99453 is linked to the device setup and patient education, CPT 99454 is reimbursable for the provision of the service and the first transmissions of measurements or alerts, with 16 data points required every 30 days.
Management codes differ and provide fixed claimable values, depending on region, based on the services delivered. Those services must include at least one interaction or live dialogue with the patient each month. Otherwise, they can consist of monitoring, clinical, and care supervision services meeting the 20-minute monthly threshold.
Where the service has exceeded the 20-minute requirement to claim CPT 99457, it can claim a subsequent reimbursement through CPT 99458 for further care management, treatment, and monitoring services each month.
Documentation Requirements for RPM Reimbursements
All the standard codes used in RPM billing should be supported by sufficient documentation and records to evidence the services delivered and the touch points with the patient where live interactions are required.
RPM services can be ordered by any physician, clinician, or suitable qualified healthcare provider. However, one of the important aspects of RPM is that services such as data tracking can be provided by delegated clinical or clerical support staff, provided they have the requisite knowledge and are working under the supervision of the prescribing practitioner.
In some cases, medical practitioners or nurse practitioners can claim supplementary reimbursements for supervisory services to monitor and manage the work provided by other more junior clinical staff.
Patient Eligibility for RPM Healthcare Programs
Contrary to popular misconception, RPM is far from only suited or available to patients with long-term chronic conditions or multiple comorbidities and diseases that make their care more complex. Instead, any patient of any demographic is eligible for RPM services where a physician feels this would be beneficial and that there is a demonstrable medical need.
Examples include patients in rural areas for whom visiting a physician in person is difficult or impossible or people with limited mobility who prefer virtual healthcare since they can monitor their condition and submit real-time data from the comfort of their homes.
However, practitioners may need to demonstrate that they have an established relationship with the patient and have a comprehensive understanding of their health and overall well-being to be able to ascertain whether RPM services will be an appropriate fit.
Criteria for RPM Devices
Any RPM program or healthcare patient service subject to an RPM reimbursement claim must have been provided with an FDA-approved medical device. Patients must have received their device, been instructed in how to use it to produce accurate data, and how to transmit those readings to their physician or the allocated supervisor.
The RPM devices provided by Wanda Health comply with all the requisite standards and conditions and provide essential functionality, such as automated data transmissions without manual programming.
RPM devices must also meet other standards to be considered reliably accurate and to collate data with sufficient precision to be used in clinical decision-making.
Understanding the Prescribing Practitioners Authorized to Claim RPM Reimbursements
Finally, it is important for any healthcare provider interested in implementing RPM services or expanding the scope of virtual care delivery to understand how the CMS and other payers, such as insurance providers, define the clinical staff authorized to submit RPM claims.
In most cases, and according to the CMS codebook, a clinical member of staff is defined as being a person working under the supervision of a qualified healthcare provider or physician and with the standing, knowledge, facilities, and accreditations to provide professional healthcare services.
While RPM monitoring staff do not necessarily need to provide direct reporting services, they must adhere to the standards and be suitably authorized to provide services. This ensures that RPM measurements that pose a potential concern are always evaluated by an accredited practitioner who can make decisions about the right interventions.
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