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Billing and Revenue RPM

Definitive Guide to CPT® Code 99457

Optimize Health | 10 January 2024
6 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 99457.

The Top Things You Need to Know to Bill CPT® Code 99457

CPT® code 99457 covers the time your clinical team spends monitoring patients and delivering remote care and patient education.

Here are the most important things you need to know to bill CPT® Code 99457 correctly.

  • Who Can Order 99457 and Provide Clinical Monitoring Services? Like all remote patient monitoring (RPM) codes, a physician or other qualified healthcare provider (QHCP) can order RPM for the patient if they believe it is medically necessary. The codes allow for clinical staff to provide monitoring under general supervision of the physician or QHCP, but state law can vary on what level clinician can independently provide RPM independently.

If a physician or QHCP conducts the monitoring, they may be eligible to bill at a higher reimbursement rate using CPT® code 99091.

  • What Activities Contribute to Clinical Monitoring?  In general, any time spent monitoring patient data or communicating with patients about their health can count toward 99457. All activities need to be documented. They include:
    • Monitoring and analyzing patient data
    • Sending any patient communication (for example, text or phone)
    • Providing ongoing patient education or communicating patient updates and patient escalations
    • Reviewing a patient’s readings with other members of the care team
    • Making changes to a patient’s care plan or medications
  • The 20-Minute and Interactive Call Requirement.  To bill 99457, clinical staff must spend a minimum of 20-minutes in a calendar month conducting the monitoring activities. Time spent on patient care must be documented in case of an audit. In addition, the clinical staff must have at least one live or synchronous, two-way, interactive call with the patient. To qualify as a synchronous communication, this must be at minimum a live phone call or video call. Text messages and/or voicemails do not meet the interactive call requirement. Even if you have met the 20-minutes of care time but have not have live conversation with the patient, you should not bill 99457.   
  • Independent Monthly Code. 99457 can be billed one-time every calendar month, but can be billed independent of the other RPM codes. In other words, if a patient only submits 14 readings in a month and therefore isn’t eligible to bill 94454, you can still bill 99457 as long as you have met the 20 minute and interactive call requirements. Additional time spent on clinical monitoring may be eligible for reimbursement using CPT® code 99458.
  • Reimbursement Rates. According to the CMS CPT© Guidebook, Professional Edition 2024, the national average reimbursement rate for 99457 is $48.13, 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 CMS.gov physician fee schedule.

Optimize Health’s Best Practices for Meeting CPT® Code 99457 Requirements

Clinical monitoring time is all about connecting with patients and building trusted relationships. When patients understand that a clinician is available to check on them every day and are truly invested in their care, they become more involved in their own health.  Here are some specific best practices to follow:

  • Set Expectations for Interactive Call at Patient Onboarding:  While expectation-setting at the RPM onboarding appointment often focuses on the number of readings that patients take, it’s critical to also set expectations for ongoing communication. Patients need to understand that they must speak with a member of the care team every month to review their progress and discuss their care plan.
  • Automated Time Tracking: Your RPM platform may automatically track time towards both the 20-minute time requirement and the interactive call. In-platform communication tools like texting and live-calling capabilities are important to make it as easy as possible to track the time spent monitoring each patient. The monitoring team should also know how to add manual time, or edit automatically captured time, if they do need to conduct monitoring activities outside of the platform, such as calling a patient from the office line or personal cell phone so that those engagement activities are always tracked and you don’t lose track of billable time.
  • Choose the Right Staffing Model:  Maintaining high levels of engagement time is dependent on dedicating enough staff time to interacting with RPM patients on a daily basis. For many practices, it can be difficult to have their staff manage remote monitoring as well as in-office priorities. In our experience, one full time clinician can monitor 150-200 patients. If your practice does not have sufficient clinical resources, you should consider an RPM partner that provides clinical monitoring. Your partner’s team can act as an extension of your own staff, expanding your practice’s clinical capacity.  We have found that practices using partner-managed RPM typically save overhead expenses related to providing these services to patients.
  • Make Calls Early in the Month and Get to Know Your Patients Schedule:  The interactive call requires planning so you can reach patients when they are most likely to be available, since voicemails do not meet the interactive requirement. We recommend reaching out to patients early in the month so there is time to make repeated attempts before the end of the month. We also suggest getting to know your patient’s preferences for days of the week and/or times in the day that works better for them. Ideally your remote care platform should have a place to note your patients’ availability and preferences for when to receive calls. 
  • Make the Interactive Call Meaningful: Patients will be more likely to pick up the phone and engage with their care team members if they find the calls to be helpful and supportive. Getting to know patients and asking about their routines, friends, family, and other meaningful connections such as pets or other being part of community groups can help build trusted relationship with patients. In addition, care team members should help patients understand how they can make changes to their diet and lifestyle to improve their health. 

Want to Learn More about Remote Care and Practice Benefits?

We can walk you through the benefits of remote care programs for your patients and your practice. Set up a free consultation with one of remote care experts to get more information and learn how Optimize Health makes it easy to get started and build successful remote care programs.