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Definitive Guide to CPT® Code 99454

Optimize Health | 09 January 2024
5 minute read

This content is designed to provide information to the reader. Any information in this blog or the additional links should not be construed as legal advice to any individual or entity, and is not provided in the context of an attorney-client relationship. Further nothing in this blog should be construed as a guarantee of reimbursement.

Remote patient monitoring (RPM) specific CPT® codes reimburse providers for providing RPM services. There are 4 primary codes that most practices use for RPM: 

  • CPT® code 99453 for initial patient set-up and education
  • CPT® code 99454 for 16 days of patient data transmission (in a 30-day period)
  • CPT® Codes 99457 and 99458 for clinical monitoring time per calendar month

This blog focuses on CPT® code 99454, which can be billed even if 99457 or 99458 are not met.

The Top Things You Need to Know to Bill CPT® Code 99454 

CPT® code 99454 covers the automated data transmission from the patient’s device to the practice’s Remote Physiologic Monitoring (RPM) platform. The code requires that patients take a minimum number of readings per month to be eligible for reimbursement. 

Here are the most important things you need to know before billing CPT® Code 99454.

  • Who can order 99454? An ordering provider (a physician or other qualified healthcare provider) can order RPM for the patient. The ordering provider should only prescribe an RPM program to a patient if they believe the remote physiologic monitoring is medically necessary. Common conditions are monitored via RPM include: hypertension, diabetes, chronic kidney disease, and chronic/congestive heart failure.
  • The 16-Day Requirement. To bill 99454, the patient must transmit at least 16 days of readings within 30 days. These readings must be taken on separate days, so if a patient takes readings twice a day for 10 days, that would only count as 10 days of readings. The reading days do not need to be consecutive, but patients are more likely to be successful if they take their readings each day. During the consent and onboarding process, here at Optimize Health we highly encourage patients to take readings daily or twice daily.
  • Billable Every 30-Days. 99454 can be billed once every 30 days. It’s not tied to the calendar month, though many practices choose to bill on a calendar basis to simplify billing.
  • Patients with Multiple Devices:  If a patient has multiple devices, the total days of readings still must be 16. However, readings from both devices will count toward the 16-day requirement. For example, if a patient takes a blood pressure and weight reading on the same day, that would count as one day of readings. Alternatively if a patient takes 8 days of blood pressure readings and 10 days of weight measurements, this would count as 18 days, as long as the days are not double counted. All devices must meet the FDA definition of a medical device, and we recommend choosing an RPM partner that provides FDA-regulated devices for at-home use. 
  • Reimbursement Rates. According to the CMS CPT© Guidebook, Professional Edition 2024, the national average reimbursement rate for 99454 is $46.50, but rates will vary by geography and location. Optimize Health does not interpret or define the CMS RPM codes and recommends that you refer to your billing specialist or MAC office for guidance. Local reimbursements can be located at physician fee schedule.

Optimize Health’s Best Practices for Meeting CPT® Code 99454 Requirements

We strongly recommend setting expectations for each patient’s engagement and participation in your RPM program during the onboarding appointment.

In addition to using cellular devices and a personalized onboarding appointment, we would also suggest:

  • Build Trusted Relationships: Patients are more likely to take regular readings when they have strong relationships with their monitoring team.  We recommend calling patients at least once a week so they feel more connected to their providers and become more invested in improving their own health.
  • Allocate Sufficient Monitoring Staff: Building trusted relationships with patients requires time, so we strongly recommend dedicating clinical staff time to the program so they can focus on providing the best remote care experience for your patients. One full- time clinician who is dedicated solely to RPM can monitor 150-200 patients. If your practice does not have sufficient clinical resources, consider an RPM partner that provides clinical monitoring. Your partner’s clinical team can act as an extension of your own practice and expand your capacity without adding overhead costs. The more your patients interact with their monitoring team, the more likely they are to take more readings.
  • A Good Platform Should Continually Track Patient Adherence: Your RPM platform should make it easy to filter and sort which patients are adhering to their RPM program. After addressing critical and out-of-threshold readings, the monitoring team can use daily workflow to look for patients who are not on track with the prescribed number of readings and should be prioritized for additional outreach.
  • Ask Questions to Understand Non-Adherence:  If patients are not taking regular readings, the monitoring team should try to uncover why. Sometimes the right question can uncover simple reasons why patients are not taking readings. For example, be sure to ask patients if their device is still working, do they truly understand how to use it, does it need new batteries, have they been traveling, or has anything happened in their personal life that is making taking readings more difficult?

    To maximize patient engagement, we recommend many of the best practices covered in the Definitive Guide to CPT® code 99453

Want to Learn More about How to Bill for RPM?

More details are available in our complete Remote Care Billing Guide (includes RPM, RTM, CCM, CCCM, and PCM codes). You can also set up a free consultation with one of RPM experts to get more information on RPM CPT® codes.