Billing and Revenue RPM

CPT® 99457, 99458, and 99091: What Healthcare Providers Should Consider

Optimize Health | 03 January 2022
6 minute read

This is the second in our series on the remote monitoring CPT® codes. Check out Part 1, which covers CPT® Codes 99453 and 99454, and Part 3, which addresses some of the most frequently asked questions regarding the remote monitoring CPT® codes.

Remote patient monitoring (RPM) programs have been quickly gaining momentum over the past few years. The COVID-19 pandemic, coupled with advances in technology, and increasing adoption among doctors and patients, have bolstered demand even further. In response, the Centers for Medicare and Medicaid Services (CMS) have activated several codes for coverage and payment of remote monitoring services.

There are five CPT® codes most relevant to providers considering an RPM program:

  • 99453
  • 99454
  • 99457
  • 99458
  • 99091

In our previous post in this series, we covered 99453 and 99454. In this post, we’ll address 99457, 99458, and 99091.

What Do CPT® Codes 99457, 99458, and 99091 Entail?

As mentioned previously, 99453 and 99454 are associated with setup, education, and supply. 99457, 99458, and 99091 reimburse for expenses associated with the provider work undertaken for remote physiologic monitoring, including medical decision making, care coordination, and patient communication. This work is most often used to help patients with chronic conditions, like diabetes, obesity, hypertension and heart failure, but could also be utilized for managing patients with a number of other chronic, acute, and subacute conditions. The goal is to support patients by partnering with them to better manage these conditions.

99457 allows monthly reimbursement for time spent performing duties related to interpreting remotely monitored physiologic data. This would include medical decision making to assess the patient’s clinical stability, communication with the patient via a synchronous two-way audio interaction, and oversight of the management and coordination of services as needed.

CMS mandates provider services of at least 20 minutes, per 30-day per calendar month in order to report these services for reimbursement. The work can be done by the ordering provider, other qualified healthcare professional (QHCP), or clinical staff under general supervision of the billing provider, as defined by your state.

99458 is an add-on code to 99457, for each additional 20 minutes of remote physiologic monitoring treatment management services provided in a 30-day calendar month.

Note that 99458 cannot be billed as a standalone code. It must be used in conjunction with 99457.

99091 is for the collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other QHCP. It can also be billed monthly, but has more requirements than 99457 and 99458.

A minimum of 30 minutes of time spent reviewing, interpreting, and reporting data digitally stored or transmitted by the patient, in addition to at least one communication (e.g., phone call or e-mail exchange) with the patient to provide medical management and monitoring recommendations. 99091 may only be billed by a physician or QHCP who may bill evaluation and management codes. More on this later.

What to Consider When Billing for 99457, 99458, and 99091

Average National Medicare Payment Amount for 99457, 99458, and 99091

According to the 2022 Medicare Physician Fee Schedule, the general national payment amount is:

  • 99457: $50.18
  • 99458: $40.84
  • 99091: $56.41

Note that these are general national Medicare payment amounts.

Commercial reimbursement amounts, on the other hand, can vary – some are higher, some are lower than others. It’s a good idea to consult with local payer representatives or a local Medicare Administrative Contractor (MAC) to get a more accurate sense of exact reimbursement rates for any given geographic region.

Clarification of “Interactive Communication” Requirement

In late 2020, CMS issued a clarification for CPT® codes 99457 and 99458stating that, an ’interactive communication’ may be an audio conversation that occurs in real-time and includes synchronous, two-way interaction that can be enhanced with video or other kinds of data. CMS also clarified that the interactive communication did not have to count as the entire 20-minutes of time required to bill 99457 and 99458 and could include time furnishing care management services as well as for the required interactive communication.

99091: Physician or Other Qualified Healthcare Professional vs. Clinical Staff

CPT® code 99091 pertains specifically to time spent by a physician or other QHCP on remote patient monitoring services. Time spent by clinical staff, even while providing care management services, cannot be counted for non-QHCPs.

According to the American Medical Association (AMA), a QHCP is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Who is considered a QHCP and who may bill remote monitoring varies depending on regulation. The following professionals are generally classified as QHCPs and may bill evaluation and management codes such as remote monitoring:

  • Nurse practitioner (NP)
  • Certified nurse specialist (CNS)
  • Physician assistant (PA)
  • Certified nurse mid-wife (CNM)

Please consult with a regulatory expert familiar with your regulatory/payer mix before confirming.

99091’s 30-Minute Minimum

As mentioned earlier, a minimum accrual of 30 minutes per month by a provider/QHCP must be met in order to bill for 99091. Many practices can find it difficult to achieve such a high number of minutes on a monthly basis. Therefore, many choose to focus on 99457 and 99458 instead.

Our Recommended Best Practices for Utilizing 99457, 99458, and 99091

Employ Easy-to-Use Technology for Patients

It’s essential to have equipment that is simple for patients. Devices that employ cellular communications technology, versus bluetooth, can ensure more reliable data collection and transmission. However, some patients may still prefer to use bluetooth.

If patients find the equipment cumbersome, there’s going to be a higher risk of non-compliance. So, it’s important to provide technology  options that meet the needs and preferences of your patient population.

Engage With Patients to Ensure Compliance

Automated notifications can help remind patients when to take their measurements. With busy schedules, mundane tasks are often overlooked in everyday life.

Platform alerts can notify a doctor’s office when measurements come in, or conversely, when they don’t. This can enable the care team to follow up with patients as needed.

Take Advantage of Automation in the Platform

Use the tools within your remote monitoring platform to automatically track activities performed by physicians, QHCPs, and clinical staff. All those incremental minutes may seem small, but they can quickly add up to the required 20 or 30-minute minimum threshold.

Choose an Experienced Remote Monitoring Partner

In order to develop a smoothly running remote monitoring program, it’s important to work with a partner that has a deep understanding of your clinical and administrative workflows and has sufficient familiarity with regulatory intricacies.

Quality Matters

Choosing the right RPM program might seem like a daunting task. It can be tempting to simply choose the least expensive option. However, it’s wise to take time to research which ones will work best for you and your patients. The level and quality of customer service and seamless technology can have a big impact on your RPM experience.

If you’d like to learn more about how we help providers across the country to deliver clinically and financially effective RPM programs, you can request a demo to see how Optimize Health can work for you.

The Optimize Health 3-Part Remote Patient Monitoring CPT® Code Series

Part 1: CPT® Codes 99453 and 99454: What Healthcare Providers Should Consider
Part 2 (current): CPT® Codes 99457, 99458, and 99091: What Healthcare Providers Should Consider
Part 3: Remote Monitoring CPT® Codes Frequently Asked Questions