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Telemedicine Reimbursement: Remote Patient Monitoring and Updated CMS Codes

November 26, 2019

Telemedicine in GeorgiaOver the past year the Centers for Medicare and Medicaid Services (CMS) has initiated significant changes in how remote patient monitoring (RPM) and other forms of telehealth and telemedicine will be coded and billed. Private payers are following suit in enacting their own billing policies and guidelines. Some states still lag with implementing Medicaid updates and other guidelines but more are starting recognize that transportation expenses and other applicable factors are impacting access to healthcare. Here, we discuss some of the most significant changes including updated CPT codes that telehealth providers and their billing staff need to know.

CMS and Remote Patient Monitoring Updates

CMS finalized their plans for reimbursing healthcare providers for certain telehealth and remote patient monitoring services, with the focus on three new CPT codes for RPM to separate it from other telehealth and telemedicine services, which carry more restrictions.

CMS administrators also recognized that access to care isn’t just an issue affecting rural providers, but a struggle for urban patients, especially homebound or with limited transportation access.

In a recent proposal, CMS is changing coverage guidelines to eliminate geographical restrictions on telehealth access by 2020 – but there’s a catch.

Preference seems to be given to participants in Medicare Advantage over Original Medicare: under Original Medicare, when telehealth coverage was expanded from strictly rural areas to cover more urban patients, restrictions forbade telehealth for managing chronic care conditions or accessing urgent care. The MA guidelines will enable urban as well as rural users to benefit from connected health technologies, with fewer restrictions, including more locations from which to access care, including their homes.

As part of the the bipartisan Budget Act of 2018, Medicare expanded dialysis services coverage for telehealth platforms from home or independent facilities provided guidelines for in-person checkups are met, while revised substance abuse treatment guidelines will offer providers better opportunities for reimbursement. Originating site requirement waivers will also enable accountable care organizations (ACOs) to use and be reimbursed for telehealth.

Reimbursement guidelines from CMS come with several revised or new codes for the following categories:

Transitional care management covers treatment up to 30 days after discharge from a hospital, and is getting its associated 57 codes tweaked for better usability.

Chronic care management is being reworked by CMS regarding services for complex and non-complex cases.

Principal care management is a new service in the physician fee schedule and will be covered by a new code for care management for patients with one serious and chronic condition.

CPT Code Updates and Changes
In 2018, CMS developed and recently introduced three new CPT codes specifically for telehealth services:

  • CPT 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.”
  • CPT 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.”
  • CPT 99457 – “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/ physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”

The last code, 99457, permits RPM services to be performed by “clinical staff”, such as RNs or medical assistants, as well as a physician or qualified healthcare professional, enabling providers to better incorporate RPM programs into a treatment plan workflow.  

CMS did not specify which technologies qualified for reimbursement, in spite of several groups having provided examples of the kinds of technologies that they felt should have codes to cover: Fitbits, smartphones, Holter-Monitors and other examples of artificial intelligence (AI) messaging, although CMS does plan to issue some guidelines for practitioners and others, at least in the interim.

CMS has also issued an interim final rule eliminating geographic restrictions for telehealth treatment services made on or after July 1, 2019 for substance use disorders or co-occurring mental health disorders.

Medicaid Concerns

Medicaid tends to be a patchwork of plans and overages that differ from state to state; however, every state currently provides some coverage for real-time audio-video telemedicine services. While 21 states provide RPM coverage with varying restrictions, only 11 states cover asynchronus (store-and-forward) telemedicine. Allowing the home to qualify as an eligible site for telehealth is underway in 14 states’ Medicaid programs. As more providers turn to telehealth to provide care for a larger swath of the population, and awareness of transportation costs and issues becomes reality, more states are expected to opt in for telehealth coverage in the near future as a cost-saving measure.

Private Payers and Policies

Private payers in 40 states and the District of Columbia currently mandate some form of telemedicine coverage, with some stipulating that telehealth services be covered the same as in-person, while others be paid at in-person rates. Maine and Georgia have passed laws expanding private payer coverage for certain telemedicine services. In addition, there is more attention being paid by states to RPM services, as by definition, it is a “virtual, distance-based service.”

Working with a Medical Billing and Practice Management Service

Since 2002, M-Scribe has been in the forefront of helping practices of all sizes and specialties boost revenues through fast, accurate claims billing and practice management guidance.

With so many changes being implemented so quickly, it’s sometimes difficult for a practice’s back office billing staff to stay current on everything that’s happening with payer telemedicine policies and CMS revisions and coding changes. Why not let M-Scribe help by ensuring that your telehealth claims are submitted on time, quickly and accurately, with the correct codes and documentation? Our state-of-the-art software and other technologies as well as trained, experienced personnel are here to help with claims and practice management concerns. Call M-Scribe at 770-666-0470 or email for a confidential, free consultation to learn more about how M-Scribe can help you better manage your revenue cycle while meeting all updated CMS and other payer regulations.  


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