99454 Provider & Patient Qualifications
The 2024 CMS final rule increases the ability of remote patient monitoring services to generate revenue while improving patient care experiences and health outcomes. The following frequently asked questions cover who qualifies to perform RPM services and who qualifies to receive RPM services.
Who qualifies for CPT Code 99454?
All remote patients covered by Medicare qualify for CPT Code 99454.
Must Patients Have a Chronic Condition to Qualify for RPM?
No. In the 2021 Final Rule, CMS confirmed that clinicians might furnish RPM services for patients with both acute and chronic care conditions.
Who is Qualified to Order, Perform, and Bill for Remote Patient Monitoring Services?
Remote patient monitoring services must be ordered, performed, and billed by the patient’s physician or other qualified healthcare professionals. Patients must undergo monitoring for at least 16 days before billing for CPT Code 99454.
According to CMS, a physician or other qualified healthcare professional is “an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privilege (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”
In addition, CMS considers a clinical staff member to be “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”
Reimbursement for Services Under 99454
All Medicare beneficiaries are eligible to participate in remote patient monitoring, though there are some requirements. The following section details the billing requirements for remote patient monitoring CPT code 99454.
What Can be Billed Under CPT Code 99454?
CPT Code 99454 services cover continuous device supply, collection, transmission, and reporting services. This code also reimburses costs for leasing a remote patient-monitoring medical device and can only be billed in a 30-day period.
CPT 99454 pays for supplying the device for daily recording or programmed alert transmissions. Code 99454 may be used once per month per patient, regardless of the number of devices the patient uses. The patient must use the device for at least 16 days per month. In addition, CPT 99454 is billable every 30 days.
What is the Reimbursement Rate for CPT Code 99454?
The average rounded national payment rate for CPT code 99454 is $46.50 for 16 days per person per month. This rate varies by region.
How Does Reimbursement Work for CPT 99454?
Providers can generate revenue by performing remote patient monitoring services. However, they must use the correct CPT reimbursement codes. For example, CPT code 99454 can be billed monthly for supplying devices and monitoring patients if the primary physician or qualified healthcare professional orders the devices for their patient. However, the physician or qualified healthcare professional must also show invoices per device and the services related to each device. In addition, CPT Code 99454 requires 16 days of patient vital sign data during a 30-day billing period.
How Often is 99454 Billed?
Qualified healthcare professionals can bill CPT code 99454 every 30 days. However, it is used only once per patient per month, regardless of the number of devices a patient uses. Therefore, providers must bill CPT Code 99454 every 30 days.
As discussed, providers may bill remote patient monitoring as ‘incident to.’ This means that third-party companies can perform RPM services under the general supervision of the billing physician.
Device Reimbursement Questions for CPT Code 99454
As mentioned, patients must use a remote monitoring device for at least 16 days a month. In addition, CPT 99454 pays for supplying the RPM device with daily recordings or programmed alerts. This final section provides answers to questions concerning remote patient telehealth monitoring devices.
Must Devices be FDA Cleared to Bill for CPT 99454?
According to CMS, devices must be “medical devices as defined by the FDA.” Medicare does not require the device to be cleared by the FDA. However, some providers may require using FDA-cleared Class II remote patient monitoring devices. If an RPM medical device is marketed as FDA-registered, it does not mean it is FDA-cleared. With FDA-cleared remote patient monitoring medical devices, healthcare organizations and patients can rest assured that they receive instant and reliable patient health data remotely.
What RPM are devices used for CPT Code 99454?
Health organizations may use several patient monitoring devices to reimburse for RPM services under CPT code 9954:
Can a Patient Use Multiple RPM devices under CPT 99454?
One patient may have several conditions and require multiple remote patient monitoring devices for reimbursement under the CPT 99454. However, in this circumstance, providers must only bill once per patient for 30 days. Again, patients must record at least 16 days of vital sign data, even when a single patient uses multiple devices.
Does CPT Code 99454 cover the device cost?
CPT Code 99454 covers the monthly servicing costs of devices and treatment services.
Outsourcing Remote Patient Monitoring Services
Remote patient monitoring reimbursement codes allow healthcare organizations to outsource RPM services to third-party remote monitoring companies. These partners can help healthcare organizations save time by performing device set-up, education, data review, and facilitating the billing processes.
Tenovi works exclusively with companies that would like to offer remote patient monitoring solutions to healthcare providers. We serve RPM service and software, chronic care management, and telehealth companies. Book a free demo with Tenovi today.
