AMA proposed changes to RPM CPT® postponed indefinitely

RPM companies are all very familiar with the CPT® code requirements for RPM. When CMS introduced the CPT® codes in 2019, only 2 readings of data in 30 days were required for reimbursement of CPT® code 99454. This led to CMS reimbursing RPM for patients who were barely using their devices and not gaining the clinical benefits of remote care.

In 2021, CMS changed the requirements for the 99454 code and required that a patient take at least 16 days of readings within 30 days. While the intent was to increase the clinical efficiency of RPM, many practices struggled to gain a high percentage of adherence to this seemingly arbitrary number of 16 days of readings.

As the industry has shifted to full-service RPM with many RPM companies providing the dedicated clinicians needed for remote monitoring, a focus on continuous quality clinical care has emerged.

These RPM companies are more routinely hitting the time engagement CPT® codes of 99457 and 99458 codes but qualifying for the 16 readings less often, as this is more out of the clinician’s control. Yet, with a higher level of engagement, the patients are still receiving clinical benefits even if they aren’t taking readings for 16 days.

RPM companies and providers have been pushing back on this arbitrary 16 number for years and the AMA’s CPT Committee has considered making changes every year. Significant new changes were proposed this year and there was hope that the AMA was finally listening, but they have once again decided to postpone making any changes.

Proposed CPT® code changes

The changes that were ultimately postponed included:

• Adding a new CPT® code that would cover 2-15 days of readings in 30 days, presumably at a lower reimbursement rate than CPT® code 99454
• Revising CPT® code 99457 to be a minimum of 11 minutes of interactive communications versus the current 20-minute minimum
• Revising CPT® code 99458 to enable billable units of 10 minutes

These proposed changes seem to reflect the understanding that there is value in providing continuous, remote care even in smaller increments. It’s a significant disappointment for the entire industry and patients that the Committee did not adopt these changes. 

Missed opportunity for clinical impact 

By lowering the threshold for any monthly billing to 2 readings and/or 11 minutes of care, RPM companies and providers could have increased the number of patients eligible for reimbursement. Beyond the financial benefit for RPM providers and companies, there was potential for real clinical improvement as well.  

For example, RPM monitoring clinicians are often encouraged to regularly review their data and take actions that maximize the number of 99457 and 99458 units they can bill. So, if there are 5 days remaining in the month, a clinician will prioritize reaching out to a patient who has already accrued 16 minutes of care vs. one with 8 minutes as they are more likely to be able to bill for 99457 for that patient. Clinical decisions are being dictated by meeting CPT® code requirements rather than the true patient needs.

Reducing the billable time increment from 20 to 10 minutes would have minimized the incentives to “game” the system to meet the code requirements. The AMA proposed changes would have prioritized clinical care over managing the codes, which would have been a clear win for everyone involved. 

Limitations on use cases for RPM

With high adherence and engagement thresholds, practices are limited in the number of patients and applications where RPM can be used.  There are conditions where RPM can provide real clinical benefit, but patients likely won’t meet the current code requirements.  For example: 

1. Weight loss: Readings are not clinically necessary every day or every other day to monitor weight loss. Some physicians are hesitant to prescribe RPM for weight loss even when it could be clinically beneficial because they know patients are unlikely to meet the 16-day reading requirements. RPM could play an increasingly important role with the increased use of GLP-1 medications for weight loss and help prevent the weight regain that many patients experience after going off the medication.     
2. Controlled hypertension: In clinical study after study, RPM has been proven effective for lowering blood pressure.  Once patients have achieved the goal of controlling their hypertension, they still need to manage it, but this may not require daily readings. The new codes would have reflected that for some patients, maintenance readings of once or twice a week may be sufficient to gain clinical benefit.

Continua supports RPM providers

If you want to grow your RPM program, Continua Systems can help by providing the largest selection of multi-network cellular devices and a comprehensive device management platform. Contact us to learn more.