Remote Patient Monitoring: 8 Things to Know for Proper Billing and Claims

Bhushan Vanjari
April 15, 2024
3:14 pm
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Did you know that 65% of doctors use RPM to manage patients’ medical conditions?

Given the rising adoption rate of remote patient monitoring, medical institutions across the world are adopting the RPM program. However, the lucrative use of remote patient monitoring offers a unique opportunity to add an additional source of income; around 24% of claims denials are observed in a doctor’s first initial consultation.

That is the reason some of the clinicians are still skeptical about starting their own remote patient monitoring program. RPM claims processing involves coding, documentation and other necessary things to ensure proper reimbursement.

Though this problem seems to be easily solvable from the surface, it is merely the tip of the iceberg. However, if you know the right place then streamlining billing and RPM claims processing can be a walk in the park.

And we have found these eight things that clinicians ignore resulting in failure to captivate the most out of their RPM program.

So, here are the eight things that must be known for proper billing and claims in remote patient monitoring programs.

Understanding Eligibility Criteria

The first element that you need to cover to enhance your billing and claims processes is understanding the RPM eligibility criteria. CMS has provided specific guidelines for the patients to be eligible for the RPM program. Patients who are usually eligible for this program are the people suffering from chronic conditions. However, depending on the severity and number of chronic conditions they are dealing with, they are further placed in Transitional Care Management, Chronic Care Management, or Principle Care Management.

CMS has not only set the RPM eligibility criteria for patients but also set some eligibility criteria for healthcare providers. For example, the providers need to be certified healthcare providers and to enroll any patient under any RPM program; they are required to have the patient’s consent with proper documentation justifying the medical history of the patient’s condition.

Documentation of all these things is extremely essential to meet the eligibility criteria set by CMS. This will help you easy clearing of claims and bills and enhance the billing process for timely reimbursement and payments.

Grasping Covered Services

The Centers for Medicare and Medicaid has outlined some of the essential services to be provided under the RPM program which are billable. This process has been made easier with specially dedicated CPT codes of RPM. However, being the healthcare provider you should know what services are billable for maximum reimbursement.

Some of the services for RPM reimbursement include physiological data collection of vitals, medication management, and patient education regarding the program and the usage of RPM devices. Along with the billable services, you should also meet another criterion to reduce denied RPM claims, which is the minimum time spent on providing services per month to quality for billing.

Mastering CPT Coding

The CMS has assigned specific CPT codes for RPM to drive accuracy in billing and claims submission. These current procedural terminology codes are used for billing RPM services provided by healthcare providers while claims are submitted for RPM. While many healthcare institutions claim to have mastered CPT coding, it is actually one of the most prominent reasons for denied RPM claims. So, to simplify the process, here is a brief overview of CPT codes used for RPM reimbursement.

CPT Code 99453: Covers RPM device set-up and patient education on device usage.
CPT Code 99454: Covers the supply of devices for daily recording and programmed alert transmissions.
CPT Code 99457: Covers initial 20 minutes of treatment by clinical staff over 30 days.
CPT Code 99458: Covers an additional 20 to 60 minutes of reimbursement in a calendar month.
CPT Code 99091: This new CPT code, introduced in 2022, covers a minimum of 30 minutes of care, medical management, and monitoring advising.

With over 11,163 CPT codes currently in use, only five of the above-mentioned CPT codes for RPM are used. That is why RPM billing best practices include relevant and accurate coding. Along with that, claims submission for RPM ensures that you meet all the documentation requirements for RPM for maximum reimbursement.

Building a Strong Care Plan

Detailed documentation is the key to ensuring that claims submission for RPM is correct and meets all the requirements. The foundation of this can be built while dedicating a care plan for the patients. One of the best practices here is to take a patient-centric individualized approach to carefully define and outline the ideal care plan for the individual. This should include specific monitoring goals, interventions, and frequency of patient interactions.

This will make the process of meeting the documentation requirements for RPM easy for you while billing. Along with that, maintain proper documentation of all patient data collection, patient interactions and patient progress. This will directly ensure the following of RPM billing best practices while easing the process to file appeals for denied RPM claims.

Partnering with Coders

Claim submission for RPM requires accurate medical coding and documentation. Along with that, the user should know how to leverage healthcare billing software for accurate code selection and application. That is why many vendors advise partnering with qualified medical coders to instill accuracy in their processes of claims submission for RPM.

Furthermore, to identify any coding inconsistencies and reduce the rate of denied RPM claims, you should regularly conduct internal audits aligned with the reimbursement timelines for RPM. This will not only give you deeper insights about your billing process but also help you enhance the RPM claims processing.

Streamlining Claims Submission

CMS have specific billing guidelines for billing and claims submission. However, there are other specific requirements that many ignore. Along with CMS requirements, you should also adhere to specific payer guidelines for claim submission. Also, remember that although electronic submission is not a common practice, not all payers adhere to the same. Knowing and adhering to those can help reduce denied RPM claims.

Furthermore, to streamline the RPM claims submission process, the first step is to document patient demographics and service details accurately. This, when combined with accurate and correct coding, will ensure a smooth claim processing.

Staying Updated on Regulations

The healthcare industry is quickly adopting healthcare technology. Such high adoption rates have fostered regular changes in the healthcare regulatory landscape. With new laws being introduced and amendments to the current ones, the regulatory landscape for RPM reimbursement and services is constantly changing. That is why it is suggested that you always stay updated with the regulations to avoid claim denials.

To stay updated with these regulations, consulting reliable sources like its official website is suggested. Otherwise, you can refer to a professional association for the latest updates.

Addressing Potential Audits

As a healthcare entrepreneur, you must know that payers also conduct audits every once in a while. Healthcare providers who have started remote patient monitoring programs have to rely heavily on appeals for denied RPM claims after payer audits. That is why it is advised to maintain detailed records and documentation to instill best practices in your RPM billing practice. This will not only help you streamline the process but act as a preparation for any audits conducted by payers.

Apart from that, it is a best practice to instill transparency in communication with payers. With open communication with payers, any problems can be directly addressed, making the process of filing appeals for denied RPM claims easy for you.

Conclusion

To streamline your billing and claims process, it is important to cover all the essential things, from understanding the eligibility criteria to CPT codes and their usage. Let this blog be your guide to instilling a robust billing and claims process.

Furthermore, to make the billing process and claims transparent, patients should be proactively engaged in their care practices and informed about everything. Encourage patients to have ongoing communications with healthcare providers, which will help improve patient outcomes and make your RPM program a success.

Frequently Asked Question’s

1. What are the eligibility criteria for remote patient monitoring services?

RPM eligibility criteria usually involve patients with chronic conditions like diabetes, heart disease, etc., along with the involvement of a physician, patient consent, and patient’s vital data collection.

2. How do I choose the appropriate CPT codes for billing RPM services?

Choosing the right code for billing RPM services can feel technical, but it’s like picking the perfect key for a lock. Here’s a simpler way to think about it:

- Setting things up: If you’re starting the program and providing equipment, use code 99453. Think of it as the key that unlocks the patient’s remote monitoring journey (as long as data is collected for at least 16 days that month).
- Monthly check-ins: Code 99457 is like your initial 20-minute conversation with the patient about their monitored data. You might also use code 99454 if daily readings are received.
- Extra time needed: If the conversation goes beyond 20 minutes, code 99458 acts like additional keys, each representing another 20-minute chunk.

Remember, this is a simplified explanation. For complete accuracy, consult a medical billing expert or refer to official CPT resources.

3. What documentation is required for successful RPM claims processing?

Successful RPM claim processing hinges on proper documentation. Key elements include:

Informed patient consent: Document consent for receiving RPM services.
Medical necessity: Justify the need for remote monitoring (condition, goals).
Device details: Specify device type, deployment date, and patient training details.
Daily data collection: Ensure recordings and review of patient-reported data.
Regular review and action: Document analysis of readings and any actions taken based on results.

Detailed records strengthen your claim and ensure proper reimbursement.

4. What are the HIPAA compliance considerations for RPM programs?

HIPAA safeguards patient data in RPM programs. Here’s the gist:

Secure technology: Ensure data encryption (both storage and transit) by the RPM vendor.
BAA: Establish a Business Associate Agreement with the vendor outlining data security responsibilities.
Authorization: Obtain written patient consent for data collection and sharing.
Internal controls: Implement staff training, data access restrictions, and breach response protocols.

5. How can I ensure data security and patient privacy in remote monitoring?

Ensure patient data security and privacy in remote monitoring by strong encryption and authorized access control, establish secure communication channels, ensure RPM device safety, and educate patients about conditions and care plans.

6. What should I do in case of a denied RPM claim?

A denied RPM claim requires investigation. Here’s a simplified approach:

Understand the reason: Review the Explanation of Benefits (EOB) for denial details. Common reasons include missing pre-authorization, incorrect coding, or insufficient medical necessity documentation.
Verify requirements: Ensure you met all criteria for RPM billing as per your insurance carrier’s guidelines.
Appeal for denied RPM claim: If valid reasons exist, gather supporting documents (e.g., clinical notes) and submit an appeal following the insurance provider’s process.

Consider consulting your billing department or a healthcare attorney for further assistance with the appeal process.

7. What are the typical reimbursement timelines for RPM services?

Reimbursement for RPM services isn’t immediate. Here’s a simplified view:

Claim submission: Submit claims after the 30-day monitoring period with at least 16 days of collected data.
Processing time: Insurance companies typically process claims within 30-45 days.
Payment: Once approved, expect payment within another 15-30 days.

The entire process can take 60-90 days on average.

8. How do I handle billing and claims processing for additional RPM services beyond monthly monitoring?

Billing for additional RPM services beyond monthly monitoring involves identifying time spent exceeding the base coverage.