Primary Care Coding Alert

And be aware of the ways the 2021 final rule changed RPM services.

Remote physiologic monitoring (RPM) programs for patients with conditions that your provider wants to monitor remotely have become increasingly popular, especially during the COVID-19 public health emergency (PHE).

But this has created a number of myths about RPM, which need to be busted in order for you to implement these programs successfully into your primary care practice.

Myth 1: Only Patients With Chronic Conditions Can Receive RPM Services.

This myth stems from guidance the Centers for Medicare & Medicaid Services (CMS) issued in 2019, where CMS “initially described RPM as services rendered to patients with chronic conditions,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. However, CMS amended this in the final rule on the 2021 Medicare Physician Fee Schedule (MPFS), and now practitioners may “furnish these services to remotely collect and analyze physiologic data from patients with acute conditions as well as from patients with chronic conditions” (Source: 2021 Final Rule at www.cms.gov/files/document/12120-pfs-final-rule.pdf).

In fact, “the only limitation CMS places on who may receive RPM services is that they are only for established patients, a limitation waived during the current public health emergency [PHE]. CPT^® has no such limitation, and from a CPT^® perspective, anyone can receive RPM,” Moore adds.

Myth 2: RPM Devices Must Be Cleared by the FDA

In order to begin RPM services, your office must first set the patient up with the equipment necessary to monitor the condition. To report this, you’ll use 99453 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment) when your practice sets up the equipment for the patient, and 99454 (… device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) when your practice supplies the device for daily recording or programmed alert transmissions of data to your practice.

The CPT^® guidelines for these codes state that an RPM device must be “a medical device as defined by the FDA [U.S. Food and Drug Administration],” which seems to be the origin of this myth. Similarly, the 2021 final rule on the MPFS states that “clearance may be appropriate,” though it goes on to note that there is “no language in the CPT^® Codebook indicating that a medical device must be FDA cleared.”

So, equipment used in RPM simply has to meet the FDA definition of a medical device, which, per section 201(h) of the Federal, Food, Drug and Cosmetic Act (FFDCA), is “an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory … recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them” (Source: http://www.fda. gov/regulatory-information/search-fda-guidance-documents/ classification-products-drugs-and-devices-and-additionalproduct- classification-issues#device).

Myth 3: Clinical Staff Can Provide RPM Services

“While clinical staff would be involved in the actual provision of 99453 and 99454, the services must be ordered by a physician or other qualified health care professional [QHP], such as a nurse practitioner [NP] or a physician assistant [PA],” Moore notes.

Additionally, the 2021 final rule on the MPFS also stipulated that personnel not employed by your practice can provide setup and education services to a patient. This means vendors supplying the equipment used in RPM services can now provide services outlined by 99453 and 99454, though under these circumstances, you would not be able to bill the patient’s insurance for the setup and education.

Other RPM services must be performed by a physician or QHP, however. In addition to the CPT^® descriptor for 99091 (Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days), CPT^® guidelines note that the services include “the physician or other qualified health care professional time involved with data accession, review and interpretation, modification of care plan as necessary (including communication to patient and/or caregiver), and associated documentation.”

And though the descriptors for 99457 (Remote 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; first 20 minutes), and add-on code +99458 (… each additional 20 minutes (List separately in addition to code for primary procedure) “recognize any time clinical staff may spend providing these RPM services, it will likely be a physician or QHP reporting the service on a claim, since clinical staff typically do not have their own provider numbers,” Moore adds.

The bottom line? “The 2021 final rule confirmed RPM can be ordered and billed only by physicians or QHPs who are eligible to bill Medicare for E/M services, which is generally consistent with CPT^®,” Moore concludes.

Myth 4: You Cannot Report RPM Services With Care Management Services

In fact, CPT^® guidelines state you should report 99457/+99458 when your physician or qualified QHP uses results obtained using RPM “to manage a patient under a specific treatment plan.” This means you can report the services along with as 99490/+99439–99491 (Chronic care management services…), 99487/+99489 (Complex chronic care management services…), and 99495–99496 (Transitional care management services…).

But, also per CPT^® guidelines, time your provider spends on these services cannot overlap with time spent on 99457/+99458, so you must carefully separate out the time your physician or qualified QHP spent providing RPM and care management, and document accordingly.

Coding alert 1: The 2021 final rule clarified that you can also count time your provider spent communicating interactively with the patient and coordinating care management services toward 99457/+99458.

Coding alert 2: “CPT^® prohibits reporting 99091 in the same calendar month as 99457 or 99491, and NCCI [National Correct Coding Initiative] does have edits that bundle 99091 into 99457 and 99491 and does not allow a modifier to override the edits. All this is consistent with the CPT^® prohibition,” Moore concludes.