How to Get Started with Billing RPM and CCM Codes in a Clinical Practice: Part 1

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Remote physiological monitoring (RPM) and chronic care management (CCM) are sets of codes that medical practices may be able to bill for many activities that they already perform for their Medicare patient population. It can be challenging to figure out where to start—a big part of that is because of the ambiguity in the wording from the Centers for Medicare & Medicare Services (CMS) that describes these codes. Also, the rules change every year.

Most practice managers have probably noticed there are dozens of companies falling over each other trying to convince clinics that they need to buy their software for their practice to bill for these codes. This is false; a practice does not need any specific software beyond their existing EHR/EMR to bill for these codes.

That said, these digital tools may be helpful for managing the process by keeping the activities organized, but they also take a chunk of the profit margin, which isn’t huge to begin with. They may even reduce staff efficiency, by way of redundant data entry between two systems. No matter what they say in a sales pitch, out-of-the-box software integrations do not actually exist.

Before any practice can consider the pros and cons of integrating this type of software, they still need to determine if RPM/CCM fundamentally makes sense for the practice. This article aims to help give practice managers a framework for how to wrap their heads around the RPM/CCM code workflow, so they may better decide if they want to run a pilot program of their own.

What are the Applications of RPM and CCM Codes?

A Medicare patient comes for their annual visit. Their physician tells them about a new program being offered by the practice. The program lets the physician monitor the patient’s health remotely, and it provides more comprehensive support for them to achieve their health goals.

The provider must inform the patient of the potential out-of-pocket cost. If the patient agrees, they sign a copy of the program form to enroll. They take a copy home and the physician scans a copy into their chart. The signature establishes the formal date of enrollment. At the end of the visit, the physician or one of their staff teaches the patient how to use a device to measure their blood pressure daily from home, with an automatic transmission of data back to clinical staff for tracking.

For the next month and each month ongoing, clinical staff track the time of their direct and indirect time on tasks for this specific patient related to the device readings, their related care provision, and relevant follow-up in the health record. For simplicity’s sake let’s call this work “activity minutes.”

Different combinations of activity minutes are required to successfully bill for different codes. Some codes can be billed concurrently, but not others. Some codes are base codes that must be billed first, before any accompanying add-on codes can be tacked on. Finally, while all codes must be attached to a National Provider Identifier, that doesn’t mean the activity minutes within them can only be performed by NPI-holding providers.

Feeling overwhelmed? You’re not alone. This is when most folks decide this is just too much for them to go further.

Not surprisingly, this confusion is the strongest selling point of companies pushing their specialized CCM/RPM software to clinics. This software can be of great value to clinics if the price point makes sense. They do this by providing some type of structure to enter activity records—like a big bucket capturing which staff member, did what activity, for which patient, for how many minutes, on which dates, and so forth. At the end of the month, it calculates the optimal code (or codes) to submit for each patient that will maximize potential reimbursement without breaking any rules.

A practice manager and their billing leader can also do this without specialized software, using a basic spreadsheet. They could even create a spreadsheet with some automated logic to make final calculations faster or add discrete activity categories in drop-down menus to improve the correct classification of activity minutes.

The bottom line is this: what CCM and RPM have in common is that they offer a mechanism for reimbursement for activities clinics are frequently already performing for established Medicare patients, but not getting paid for…yet.

A practice can choose to bill for CCM and not RPM, RPM and not CCM, or both—not just within the same clinic, but sometimes for the same patient. It just depends on what the patient can qualify for and if they’ve been set up with a connected device.

A core difference to remember is that RPM requires connected technology and automated transmissions to your staff, while CCM is centered around the activities and communications that take place outside of traditional evaluation and management (E&M) encounters.

Consider the Practice Structure and Disease Groups

Is the clinic specialized for acute care? Is the patient population treated overwhelmingly for chronic diseases or general internal medicine?

Consider a hip and knee replacement surgical group. Chances are, they’re already being reimbursed with a bundled payment for the entire process soup to nuts, so that’s not a fruitful area for trying to implement these codes. In general, bundled reimbursements will render RPM and CCM off-limits.

Another consideration directly relevant to reimbursement is whether the practice constitutes facility or non-facility charges for Medicare payments. Facility reimbursements are not only lower than non-facility ones, but also not all of the RPM and CCM codes are eligible if billing as a facility. For simplifying this discussion, we will write for the scenario of a non-facility practice.

Consider the Payer Mix

At the time of this publication, there are few private payers that reimburse for these codes, but Medicare patients are eligible in all 50 states. Medicaid patients are also eligible in certain states, so be sure to check the state-specific guidelines.

It’s likely over time that private payers will adopt similar reimbursement structures, but we aren’t there yet, so consider the implementation burden with respect to how many patients are even theoretically financially eligible.

Components of the Remote Physiological Monitoring (RPM) Codes

RPM codes are centered around biometric data capture and transfer. The code requires use of a device that captures biometric data variables and automatically transmits the data to the practice at least 16 days out of 30. The billable activities are relatively modular, which allows for great flexibility to meet patient needs without overbilling or imposing staff labor burdens.

Let’s walk through each piece of the code set.

Service Initiation (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.”

After the provider obtains a signed consent from the patient, the next step is the formal set-up interaction. This is where the staff provide the patient with the device, teach them how to use it, and emphasize how often they need to do so.

This code may only billed once. Per current guidelines, one cannot bill again even if the provider changes the device later on and must take the time to re-educate the patient on use. (This may change in the future.)

Setting up multiple devices does not allow one to bill multiple charges, but it does add cost and confusion, so if a provider feels that they need to gather multiple biometric variables, one device with multiple functions may be better than multiple devices with one function each.

Data Transmission (99454). “Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; each 30 days.”

This code offers great bang for the buck because a practice can be reimbursed for passive data collection and nothing more. A good example would be if the provider sets up parameters for a normal data range on their end, and the provider only receives an alert if the biometric reading falls outside of that range, triggering the flag for review.

If no abnormal readings come in for that patient on that month, they can still bill this code simply because the set-up exists and because 16 or more readings were collected.

Note that if the software fails to alert the provider of an abnormal reading and the patient suffers any injury as a result, the provider and practice can be found liable for damages. Choose the technology carefully and ensure that any device choice has been thoroughly vetted by an appropriately trained and licensed attorney, to minimize any potential liability from technology failures.

Data Analysis & Interpretation (99091). “Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/ or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.”

This code is intended to reimburse for the time spent reviewing the biometric data and does not require any interaction with the patient in real-time or otherwise. If clinical staff, under supervision of the provider, can accrue 30 minutes of time reviewing and charting notes on this month’s data, then the provider can sign-off on these staff-entered notes, and under their provider NPI, bill for this code as well. This applies even to staff who otherwise do not possess credentialing to generate traditional fee-for-service charges.

It gets better: the clinic can still benefit from data review time activity even if the total falls short of the 30-minute minimum on any given month. Let’s say, for example, that the staff only managed to accrue 15 minutes of data review time activity this month. Instead of billing for 99091, the practice can instead perform and log an incidence of interactive communication with the patient or caregiver. Use this to increase the total time up to 20 minutes, and the practice can then bill instead for the next code: 99457! Neat, right?

Just make sure that staff are never double-counting any activity minutes. When accruing and submitting minutes to use for one code, consider those minutes “used up” by doing so. The practice needs additional minutes to bill for further codes.

There are never exceptions to this no-double-counting rule, so tracking time activity minutes and assigning them to the billing codes each month must be handled carefully. Again, this is an area to highlight the benefit of the many software offerings designed for managing RPM/CCM code billing. They help to ensure no double-counting on the activity minutes time accruals.

Treatment Management Services (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; initial 20 minutes).”

This code covers interactive communication with the patient or caregiver that is related to that month’s data readings. The provider (or clinical staff under their supervision) can track the minutes of interactive communication time. This isn’t just phone call interaction but also time spent emailing or messaging the patient (in HIPAA-compliant software, of course).

It can also include time preparing for the interaction itself, or post-interaction charting wrap-up. Once 20 minutes are reached over the course of the month, this code may then be billed in addition to the rest. And just like before, this does not need the provider to perform the activity directly; this can be done by clinical staff, so long as they are operating under the supervision of the provider, who still signs off on the charges to finalize them for submission each month.

While activity minutes that fall short of the 99091 time minimum can be re-directed to instead accrue for the 99457 time minimum, it is also possible to bill for both codes in the same month, if you accrue the required minutes for each. If staff can accrue 30 minutes of time looking at patient data and charting their thoughts on it, and also accrue 20 minutes of time communicating with the patient or caregiver about that data, then the practice can bill for both 99091 and for 99457 in the same month.

Additional Interactive Communication (99458). Each additional 20 minutes of treatment management services.

Keep counting any additional minutes spent in communicating with the patient or caregiver after that first 20 because if staff manage to accrue another 20-minute time block after they fulfilled all the requirements for the initial 99457, then they can add yet another charge in the same month.

There is no stated limit as to how many of these can be added for a patient each month; however, excessive use of the add-on codes month after month may trigger a review and possibly an audit. So be certain that the charges are clearly medically justifiable and consider if an E&M visit may be more efficient in resolving the patient needs if repeated communication is not changing the patient situation.

One Year, One RPM Patient: What Can the Practice Expect to Earn?

What can the practice expect to earn from its RPM patients in a month?

Let’s calculate some revenue estimates for a non-facility practice, using CMS national payment amounts. (These may be higher or lower depending on the MAC locality of the practice. Always consult the CMS Fee Schedule calculator for the most up to data specific to the area.)

Here are the 2021 national payments by code for a non-facility:

Code Description Non-Facility Price
99453 Initial Set-up $19.19
99454 16+ days of data transmission every 30 days $63.16
99091 30 minutes reviewing data $56.88
99457 20 minutes communicating with patient about data $50.94
99458 Each additional 20 minutes of communicating with patient $41.17

What can the practice earn with this patient in the first year of RPM billing? They can bill for the initial setup for $19.19. Activate the device in a way that ensures the minimum 16 or more days of transmission each month at $63.16 each, and after 12 months, that’s another $757.92 in revenue just for receiving data.

Let’s also assume that there were six times in which the data was outside of the normal threshold, alerting staff to review the data and prepare it for the provider to check, comment, and sign off on follow-up instruction. They were careful to make sure they accrued 30 minutes at each occurrence, so that’s another $341.28 in revenue.

Turns out one of those six incidents was close enough to the threshold that the provider said no follow-up contact is needed, but for the other five, the patient needed to be told to adjust their medication and to answer a few questions about symptoms. Each of these five incidents accrued at least 20 minutes of staff time to communicate and chart the discussion details appropriately, so after the provider reviews and signs off on those details, that generated another $254.70 in revenue.

Of those five months with communication, two of them were a bit more complex, and not only did staff surpass the initial 20 minutes of interaction, but also surpassed 40 minutes, so the practice billed twice for the add-on time code, generating another $82.34 in revenue.

Code Description Non-Facility Price Charges in the year Total Revenue
99453 Initial Set-up $19.19 1 $19.19
99454 16+ days of data transmission every 30 days $63.16 12 $757.92
99091 30 minutes reviewing data $56.88 6 $341.28
99457 20 minutes communicating with patient about data $50.94 5 $254.70
99458 Each additional 20 minutes of communicating with patient $41.17 2 $82.34
$1,455.43

At the end of the year, the practice will have generated a total of $1,455.43 in additional revenue for incremental labor efforts predominantly provided by clinical staff (and not by the provider directly)—for just one RPM patient.

In Part 2 of this series, we will work through the same model of discussion but on the two sets of CCM charges (simple and complex).

In Part 3, we will conclude with a discussion on concurrent billing of RPM and CCM codes and provide a step-by-step process to calculate the estimated labor costs of the components from a mix of providers and staff.

After completing these steps, readers will have the fundamental pieces needed to estimate a basic return on investment of an RPM and/or CCM program within their clinical practice for consideration of a pilot program.

Elizabeth Bradford Kneeland, MBA
Elizabeth Bradford Kneeland, MBA
Writer

Elizabeth Kneeland is a telemedicine and sleep medicine innovator living in Philadelphia. As the director for Crozer Health System sleep labs, she oversees the process, staff, and technology required to diagnosis a wide range of sleep disorders. Her career focus has straddled novel operational and financial modeling, as well as traditional academic research, providing her with a unique perspective in programmatic development and care optimization strategy.

Kneeland built the first for-profit telemedicine program for the University of Pennsylvania Health System in 2015. She also has helped build and scale sleep medicine startups in the U.S., as well as in China and Taiwan. She has co-authored publications in peer-reviewed journals on topics ranging from device validation to clinician-level educational interventions and has been an invited speaker at medical conferences throughout the U.S., China, and Taiwan.

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