Primary Care Coding Alert

Question: My company, FirstVitals, is credentialed with Medicare and all commercial insurances in our state. While we can bill Medicare directly as a physician extender practice, we bill the provider for our professional services, and they, in turn, bill Medicare for their reimbursement. However, is it possible for us to bill Medicare for the new CPT^® remote patient monitoring (RPM) codes G0506, 99453, and 99454 given that we, not the provider, are managing the technology platform?

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Answer: According to the Medicare Learning Network booklet “Chronic Care Management Services,” G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)) “is reportable once per CCM [chronic care management] billing practitioner, in conjunction with CCM initiation.” Assuming the provider who is otherwise billing Medicare initiated the CCM for which your company is providing professional services to the billing provider, you cannot bill for this service, because the provider in question (rather than your company) would have provided it (if applicable) at the time CCM was initiated, and as noted, it can only be reported once per CCM billing practitioner.

Codes 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) and 99454 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) are a different story. CPT^® guidelines preceding the CCM codes do not list either 99453 or 99454 among the codes that cannot be reported concurrently with the CCM codes. Similarly, CMS’s National Correct Coding Initiative (NCCI) edits do not have any edits involving 99453 or 99454 and the CCM codes. Thus, if you provide these services and are eligible to bill Medicare directly, as indicated, you may bill Medicare for them, as long as you are not also billing the provider furnishing CCM and that provider is not billing for the same services to the same patient.

This means that you should probably stick to your current billing model as it relates to G0506 and bill the physician for your services, leaving the Medicare billing to the CCM provider’s office. However, you can consider reporting 99453 and 99454.

Source:  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf