99091 and 99457 should be used to capture the physician or other qualified health care professional (QHP) work in remote physiologic monitoring.
For 99091 a patient’s advance consent is required for the service, and it must be documented in the patient’s record. A physician or other qualified health care professional must have seen the patient within the last year face to face. Initiation of the service must be done in person. An “advanced beneficiary consent” for the service needs to be obtained and documented in the medical record. The service should be reported no more than once in a contiguous 30-day period. Once 30 days has accrued, the service may be reported again within the subsequent 30 contiguous days (or later). The service can be reported once a total of 30 minutes of work is spent reviewing data, writing reports, and or modifying a patient care plan within the 30 contiguous days. The provider must document the timer spent assessing, reviewing and interpreting the data, the time spent communicating with the patient and/or caregiver.
To remain eligible for reimbursement under CPT code 99091, the provider must also:
- Include the time spent assessing, reviewing and/or interpreting the data in the billing code
- Include time spent communicating with the patient (and family caregiver, if applicable), along with the details of the conversation, in the billing code
- Make use of digital tools “in such a way that allows them to provide ongoing guidance and assessments for patients outside of the in-office visit,” including “the collection and use of” patient-generated health data (PGHD)
- Make use of platforms and devices that work as part of an “active feedback loop,” providing data in real time (or near-real time) to the care team as well as offering patients automatic and ongoing one-way guidance. It’s important to note that the CMS considers “passive platforms or devices” that collect but do not transmit PGHD as ineligible for reimbursement under the RPM code.
It’s also worth noting that the provider’s billing time under CPT code 99091 should be considered as equivalent to the typical times for evaluation & management (E/M) office visits.
Code 99457 can be reported every calendar month rather than every contiguous 30 days such as for 99091. 99457 requires 20 or more minutes of physician time per month compared to 30 or more minutes with 99091. 99457 requires live interactive communication with the patient for management in this time window whereas 99091 requires any form of communication with the patient. 99457 requires the device be an FDA approved device that is prescribed by a physician or QHP, but these are not specified for 99091.
99457 was newly implemented for reporting in 2019 and there is no historical utilization data available, for review. Therefore, the AASM Coding and Compliance Committee recommends that members communicate with Medicare Administrative Contractors and private payers to determine the most appropriate code(s) for reporting remote monitoring services, as payer requirements differ.