SPECIAL BULLETIN COVID-19 #48: Telehealth Clinical Policy Modifications - Remote Physiologic Monitoring Services

Friday, April 17, 2020

NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid beneficiaries. These changes are retroactive to March 10, 2020, and will end the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.

This Bulletin temporarily adds coverage for providers to help their patients engage in Remote Physiologic Monitoring (RPM), providing the opportunity to improve management of diseases and engage patients in their own care. RPM is the ongoing surveillance and interpretation of patients’ physiologic data, digitally transmitted by the patient and/or caregiver to the provider. RPM requires use of a device that is defined by the FDA as a medical device, which is wirelessly synced where the provider can evaluate the data. Providers will generally need to provide the RPM device/equipment for use by the patient, although reimbursement for such costs is available through code 99454 (below).

In Special Bulletin COVID-19 #43: Telehealth Clinical Policy Modifications - Self-Measured Blood Pressure Monitoring, NC Medicaid separately added temporary coverage for self-measured blood pressure monitoring (SMBPM). RPM is distinct from SMBPM and other forms of patient self-monitoring because RPM specifically requires use of a device that is wirelessly synced where it can be evaluated in real or near-real time. In contrast, under SMBPM, the patient must take action to report readings to the provider.

NC Medicaid will continue to evaluate telehealth and related policies and will release temporary flexibilities and guidance as needed throughout the state of emergency.

Specific guidance related to billing and coding is detailed in the section “Temporary Modifications to Attachment A.”

Remote Physiologic Monitoring (RPM) Policy Modifications

Eligible Services

  • RPM is the collection and interpretation of a patient’s physiologic data digitally transmitted to the eligible provider. Codes 99453 and 99454 are used to report RPM.
  • RPM treatment management services are the use of the RPM results by the eligible provider to manage the patient’s treatment plan. Codes 99457 and 99458 are used to report RPM treatment management services.
  • RPM and RPM treatment management services are available to established patients.
  • Specific rules and restrictions apply to the use of the RPM and RPM treatment management services codes (guidance included in C.1.a of “Temporary Modifications to Attachment A” listed below).

Eligible Devices and Set-Up

  • The device used to capture a patient’s physiologic data must meet the FDA definition of a medical device. For more information, see: https://www.fda.gov/medical-devices.
  • To bill for RPM services, patients’ physiologic data must be wirelessly synced where it can be evaluated. Transmission can be synchronous or asynchronous (i.e. data does not have to be transmitted in real time as long as it is automatically updated on an ongoing basis for the provider to review).

Eligible Providers

  • Physicians, nurse practitioners, physician assistants and certified nurse midwives are eligible to bill for RPM and RPM treatment management services.
  • FQHCs, FQHC Lookalikes and RHCs can bill under fee-for-service reimbursement for services provided by physicians, nurse practitioners, physician assistants or certified nurse midwives.

Prior Authorization and In-Person Examinations

Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving RPM services.

Temporary Modifications to Attachment A: Claims-Related Information

Retroactive to March 10, 2020, through the conclusion of the state of emergency related to COVID-19 or when the policy modification is rescinded, NC Medicaid is temporarily modifying Attachment A. Provider(s) shall comply with the “NCTracks Provider Claims and Billing Assistance Guide,” Medicaid Bulletins, fee schedules, NC Medicaid’s clinical coverage policies and any other relevant documents for specific coverage and reimbursement for Medicaid and NC Health Choice.

A. Claim Type

Professional (CMS-1500/837P transaction)

B. International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS)

Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for code description, as it is no longer documented in the policy.

C. Code(s)

C.1. Remote Physiologic Monitoring (RPM)

The following new codes may be billed by physicians, nurse practitioners, physician assistants and certified nurse midwives; FQHCs, FQHC Lookalikes and RHCs can bill under fee-for-service reimbursement for services provided by physicians, nurse practitioners, physician assistants, certified nurse midwives.

Code

Description (See 2020 CPT Code Book for Complete Details)

99453

Remote monitoring of physiologic parameter(s)(e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment

99454

Remote monitoring of physiologic parameter(s)(e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission

RPM Coding Guidance

  • Code 99453 should be billed only once for each episode of care. An episode of care is defined as beginning when the RPM is initiated and ends with attainment of targeted treatment goals.
  • Code 99454 may be billed every 30 days continuously (not calendar month, by contrast with code 99457 below).
  • Codes 99453 and 99454 cannot be reported if monitoring is less than 16 days in duration.
  • Codes 99453 and 99454 can be used for blood pressure RPM if the device used to measure blood pressure meets RPM requirements. If the patient self-reports blood pressure readings, the provider should instead bill SMBPM codes 99473/99474.
  • If the services described by code 99453 / 99454 are provided on the same day the patient presents for an evaluation and management service to the same provider (whether by telehealth or in person), these services should be considered part of the E/M service and not billed under code 99453/ 99454.
  • Providers should not report codes 99453 or 99454 if the services are included in any other codes covered by NC Medicaid for the duration of time of the RPM (for example, continuous glucose monitoring that is covered under code 95250).

C.2. Remote Physiologic Monitoring (RPM) Treatment Management Services

The following new codes may be billed by physicians, nurse practitioners, physician assistants, certified nurse midwives; FQHCs, FQHC Lookalikes and RHCs can bill under fee-for-service reimbursement for services provided by physicians, nurse practitioners, physician assistants, certified nurse midwives.

Code

Description (See 2020 CPT Code Book for Complete Details)

99457

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes

99458

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes

RPM Treatment Management Services Coding Guidance

  • Codes 99457 and 99458 require a live, interactive communication between the patient or caregiver.
  • Code 99457 should be billed for the first twenty minutes of communication with the patient or caregiver in the calendar month. This code may be billed only once per calendar month per patient.
  • Providers may not bill code 99457 or 99458 for interactions of less than 20 minutes.
  • If the services described by code 99457 and 99458 are provided on the same day the patient presents for an evaluation and management service to the same provider (whether by telehealth or in person), these services should be considered part of the E/M service and not billed under these codes.

D. Modifiers

  • Provider(s) shall follow applicable modifier guidelines.
  • Modifier CR (catastrophe/disaster related) must be appended to all claims for CPT codes listed in this policy.

E. Billing Unit

Provider(s) shall report the appropriate code(s) used which determines the billing unit(s).

F. Place of Service

Telemedicine claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not Place of Service (POS) 02 (telehealth). 

G. Copayments

For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1, located at https://medicaid.ncdhhs.gov/.

H. Reimbursement

Provider(s) shall bill their usual and customary charges. For a schedule of rates, refer to https://medicaid.ncdhhs.gov/.

Additional Resources

Contact

NCTracks Contact Center: 800-688-6696