Telehealth, telemedicine, remote medicine, mobile Health (mHealth), remote patient monitoring – all buzzwords you likely heard during the pandemic, if not before. Technology has always and will always impact how we deliver healthcare, but now it is also impacting where we deliver healthcare. The trend toward virtual meetings – with our doctors or anyone – was already taking root as the technology enabled it. And COVID-19 certainly accelerated it.
Telehealth visits have increased dramatically since COVID-19. While visits peaked in April of 2020, they are still 38 times greater in 2021 than pre-pandemic. Only 11 percent of consumers used telehealth in 2019 for an estimated $3 billion in telehealth spending. In May of 2020, 46 percent of consumers used telehealth to replace canceled visits. Consumers are growing increasingly comfortable with telehealth with 40 percent stating they plan to continue using telehealth in the future compared to 11 percent pre-COVID. This could shift up to $250 billion of US healthcare spending to virtual care.
Remote Patient Monitoring (RPM), is one specific type of telehealth that is growing in provider and consumer acceptance, largely driven by CMS reimbursement for remote patient monitoring. In November of 2018, CMS announced three new codes for Remote Patient Monitoring that became effective January 1, 2019. In January of 2020, CMS implemented significant changes to the codes, including reimbursement for remote treatment management by clinical staff such as nurses and medical assistants. These changes facilitated rapid growth in RPM adoption. By the end of 2020, 23.4 million patients were using RPM and this is projected to grow to 30 million by 2024.
CMS’ expansion of the codes reflects the clear clinical benefits of proactive, preventive care. If you are considering starting an RPM program or have an RPM program that is not performing at the level you would like, this Playbook will be an invaluable resource. We will walk through each of the necessary stages to launch or relaunch and improve your RPM program, including both the clinical and financial performance.
The Complete Remote Patient Monitoring Playbook
What you need to know to launch and manage a successful RPM program includes 7 stages:
Billing for RPM Services
Stage 1: Understanding Remote Patient Monitoring
Before jumping into how to create a Remote Patient Monitoring program, we find it helpful to understand some of the basics of RPM. This section covers:
- What is RPM?
- How RPM works
- RPM eligibility requirements
- Chronic Care Management (CCM) and how it differs from RPM
- The Growth in RPM
- Benefits of RPM
What is Remote Patient Monitoring?
Remote Patient Monitoring (RPM), is the collection of Patient-Generated Health Data (PGHD) by a patient or caregiver outside of a traditional clinical setting that is digitally stored and transmitted to a physician, Qualified Healthcare Professional, or clinical staff for review, analysis, care management, and intervention by a Qualified Healthcare Provider (QHCP) or Clinical Staff as appropriate.
What exactly does that all mean? Let’s break down each part of that definition.
Patient-Generated Health Data (PGHD) – Patient or their caregiver uses a device, such as a blood pressure cuff or weight scale, to take their own readings.
Outside of a traditional clinical setting – Readings are taken at a patient’s home or other convenient location (but not at the physician’s office).
Digitally stored and transmitted – Data from the device automatically syncs with software at the physician's office.
Review, analysis, care management, and intervention – The data is used to monitor the patient for out-of-threshold readings, analyze trends in readings, provide a patient-specific treatment plan, care interventions as needed, and ongoing patient education.
By a Qualified Healthcare Provider or Clinical Staff – Appropriate clinical staff, including nursing staff or medical assistants are providing care to the patient.
According to the U.S. Government Accountability Office, “Remote patient monitoring refers to a coordinated system that uses one or more home-based or mobile monitoring devices that transmit vital sign data or information on activities of daily living that are subsequently reviewed by a healthcare professional.”
What exactly does that all mean? Let’s break down each part of that definition.
Coordinated system – Patient and physician's office are using a common platform or technology to take and share readings.
One or more home-based or mobile monitoring devices – Patients or their caregiver uses a device, such as a blood pressure cuff or weight scale, to take their own readings.
Transmit vital sign data or information on activities of daily living – Data from the device automatically syncs with software at the physician's office.
Subsequently reviewed by a healthcare professional – The data is used by appropriate clinical staff, including nursing staff or medical assistants, to monitor the patient for out-of-threshold readings, analyze trends in readings, provide a patient-specific treatment plan, care interventions as needed, and ongoing patient education.
According to the Institute for Health Policy and Leadership, “Remote patient monitoring is the collection, storage, and evaluation of health information (patient’s vital signs, blood sugar levels, etc.) through live monitoring via devices that transmit information from the home or care facility to a provider.”
What exactly does that all mean? Let’s break down each part of that definition.
collection, storage, and evaluation of health information – data is collected to monitor the patient for out of threshold readings, analyze trends in readings, provide a patient-specific treatment plan, care interventions as needed, and ongoing patient education.
through live monitoring via devices – patients or their caregiver uses a device, such as a blood pressure cuff or weight scale, to take their own readings.
that transit information – data from the device automatically syncs with software at the physician's office.
from the home or care facility – readings are taken at a patient’s home or other convenient location (but not at the physician’s office).
to a provider – appropriate clinical staff, including nursing staff or medical assistants are providing care to the patient.
Who is Eligible for Remote Patient Monitoring?
While RPM is typically used for patients with chronic or acute conditions, NO formal diagnosis is required. While hypertension is one of the most common use cases for RPM, many conditions can be effectively monitored with RPM.
CMS does have enrollment criteria, including:
- The patient must consent to participation in the program
- The devices must be defined as medical devices by the FDA and be ordered by a qualified medical professional
- Data captured by a device must be wirelessly synced/connected
Data monitoring services must be performed by a physician, a qualified healthcare professional, or clinical staff (such as RNs/medical assistants), subject to state law
What is Chronic Care Management (CCM)?
Chronic Care Management (CCM), introduced by CMS in 2015 as a separate service, enabled providers to be paid for care that was managed between office visits. CCM CPT® codes cover clinical staff for establishing, implementing, revising, and monitoring comprehensive care plans for patients with two or more chronic conditions that put the patient at significant risk.
Patients in Chronic Care Management programs are often great candidates for Remote Patient Monitoring and they can participate in both programs.
RPM vs. CCM
Unlike CCM, RPM does not require a specific diagnosis. CCM requires multiple conditions lasting at least 12 months for eligibility, so many patients that are not eligible for CCM, will still be eligible for RPM. RPM can also be used for acute applications, beyond chronic conditions, such as medication management, behavioral health, and more. CCM and RPM use different CPT® codes, so a practice can bill for both but cannot apply the same minutes of engagement to multiple CPT® codes.
Additional requirements exist for billing each potential CPT® code for Remote Patient Monitoring and are covered in the billing stage of the playbook.
How RPM Works
As depicted below, RPM can be summarized into 4 steps – all of which we will dive into more detail in subsequent stages of the playbook.
- Patient Onboarding: Key steps in the patient onboarding process include identifying an RPM-eligible patient, securing an order for RPM from the provider, collecting patient consent (written or verbal), and completing a patient onboarding appointment for device setup and education.
- Transmission and Collection of Physiological Data: Once the patient is educated on how to use their RPM-enabled device, it is their responsibility to take regular readings at home, which will be automatically transmitted to the provider. An important RPM distinction is that the monitoring is done at the patient’s home or long-term care facility. It is not the same as inpatient monitoring which is done in a hospital by clinical staff.
- Evaluation, Management, and Engagement: Clinical staff establish treatment plans to improve patient conditions, clinical goals, and escalation processes to engage with each patient in a meaningful way.
- Billing and Reimbursement: RPM is a significant time commitment for clinical staff and CMS will reimburse clinics for that effort. We recommend using software that makes it easy to track the requirements for billing each RPM CPT® code and maintain an audit trail.
What is Fueling the Growth in RPM?
Remote patient monitoring is expected to grow at an average annual rate of 23 percent to hit $85 billion in the United States by the end of 2026. The increasing age of the population as well as the prevalence of chronic diseases is driving healthcare expenditures and the need for more preventative measures to reduce costs.
More than 40 percent of Americans – 133 million - have a chronic condition and 81 million Americans have more than one chronic condition. 90 percent of the $3.8 trillion spent on healthcare in the U.S., or 17.7 percent of the total US economy, is for chronic and mental health conditions. This is creating a healthcare spending crisis in the United States, where on average, the US spends twice as much as other wealthy nations on healthcare.
With those statistics, it’s no surprise that CMS is shifting towards value-based care and preventative medicine. The New England Journal of Medicine defined the benefits of Value-Based Care for each stakeholder in the healthcare landscape:
The shift to value-based care means looking holistically at the resources available and the best ways to deliver care that improves outcomes while lowering costs. In other words, reserving the most expensive resources - acute care hospital stays - for only the patients and procedures that absolutely require it and using less expensive resources, like home-based care, when possible.
While this all sounds great, a 2019 survey revealed that two of the largest barriers to adopting value-based care were:
- Trouble with collecting and reporting patient information (i.e. gaps in care)
- Lack of resources (short-staffed, insufficient healthcare IT software, etc.), particularly with population health initiatives
Not only has Remote Patient Monitoring been proven to reduce acute care use and hospitalizations, it also has the potential to overcome the barriers to value-based care. At-home, daily monitoring with automatic transmission of readings solves the gaps in care and enables providers to collect and analyze patient data between visits. Easy-to-use RPM software and outsourced monitoring can make a huge dent in the resource issue.
The COVID-19 pandemic didn’t create the trend toward proactive monitoring of chronic conditions, but it has certainly accelerated the demand for remote care. 60 percent of people now report being very interested in remote care or telehealth. 68 percent of physicians are using or plan to use remote patient monitoring. 25 percent of people are comfortable switching providers, which means you could lose patients if you are not offering telehealth and remote patient monitoring.
And CMS is evolving the reimbursement landscape to incent value-based care. In 2018, CMS made dramatic changes to how they pay for home health, “refocusing on the needs of patients, promoting innovation, and reducing burden for physicians and home health providers,” including payment for Remote Patient Monitoring.
With technology breaking down barriers to value-based care, we expect CMS will continue to expand reimbursement strategies that align with incentives for better outcomes at lower costs. And while many of these programs are voluntary now, practices should be prepared for potential mandatory value-based care programs in the future.
Benefits of Remote Patient Monitoring
Remote Patient Monitoring, when implemented correctly, is truly a win-win-win for medical staff, patients, and the overall healthcare system. RPM transforms chronic disease care from reactive to proactive – improving health and the care experience while reducing costs.
Many patients with chronic conditions only see their physician when their health starts to deteriorate or they have a routine, periodic office visit scheduled. With RPM, patients can effectively be checked on by clinical staff every day. With a proactive care plan that makes the right adjustments to medications and treatment based on daily feedback, we can prevent possible deterioration in health between office visits.
Many patients are already used to taking readings, such as blood pressure or blood sugar, at home. However, these patients are often writing down their readings with paper and pencil and not sharing the data with their physician’s office, so they are essentially on their own for figuring out how to interpret and act upon that information. RPM can not only reduce the burden of using paper and pencil with automatic transmissions, it also allows clinically-trained experts to be involved in the daily assessment of the data.
RPM provides unique clinical benefits because it helps healthcare providers gain a greater understanding of their patients’ health outside of their routine appointments. With the ability to collect data over time, chronic conditions can be treated in the broader context of a person’s lifestyle, leading to more impactful education opportunities and interventions. Numerous clinical studies have demonstrated the effectiveness of RPM in generating positive outcomes across various conditions.
RPM is truly a partnership between the medical practice and the patient with significant benefits to both parties.
- Improved patient outcomes, including improved hypertension control, lower A1C levels, reduced heart failure exacerbation
- Regular communication with patients between visits for ongoing engagement
- Increased trust and connection with patients
- Improved revenue cycle with reimbursement from RPM CPT® codes
For more information on clinical benefits, see the Choosing Conditions section of the playbook and for more detailed information on financial benefits, see Billing for RPM stage of the playbook.
- Potential for reduced doctor visits, hospitalizations, nursing home admissions
- Potential for reduced adverse outcomes and improved quality of life
- Ability to take greater control of health
- Comfort in having medical team checking on them daily
- Covered by Medicare and many insurances
- Potential to decrease overall healthcare costs
Stage 2: Understanding Remote Patient Monitoring
Now that you have a clear understanding of the benefits of RPM, the next stage in the RPM playbook is choosing the conditions that you want to monitor at your practice and choosing the associated devices. This stage will include:
- Why chronic diseases are a good fit for RPM
- Popular chronic diseases for RPM
- Additional RPM applications
- Common RPM-enabled devices
- Bluetooth vs. cellular devices
Chronic Conditions and RPM
Choosing conditions for RPM will vary based on your patient population and can evolve and expand over time as your RPM program grows. Many practices focus on prevalent conditions in their practice to start, such as hypertension, and then expand as their staff becomes more proficient in RPM onboarding and monitoring. Others go all-in and select multiple conditions and devices from the start.
While RPM has many applications, a common place for practices to start is chronic conditions. Chronic conditions are very prevalent (1 in 6 adults in the U.S.) and very costly. There is also a tremendous opportunity to improve outcomes and reduce the risk of death and disability with proactive monitoring.
Remote Patient Monitoring (RPM) programs have been proven effective in managing various types of chronic conditions. Below are some of the most common conditions that medical practices are using RPM to treat and the associated devices for each condition.
The next sections will dig into each of these common chronic conditions and why they can be a good fit for Remote Patient Monitoring.
With almost half of all adults in the U.S. having hypertension, it’s no surprise this is one of the most common use cases for Remote Patient Monitoring.
- Over 100 million people have high blood pressure
- Only 1 in 4 adults with hypertension have their condition under control
- High blood pressure is a risk factor for heart attacks, strokes, and heart failure and was a primary or contributing cause of death for nearly 500,000 Americans in 2018
Monitoring blood pressure daily allows care teams to create and modify treatment plans that support heart-healthy lifestyles. More proactive management of high blood pressure can also help ensure patients that take blood pressure medications are using them correctly and can even lead to a decrease in required medication if a patient’s blood pressure can be controlled through monitoring. Improving control of blood pressure can decrease the risk of a heart attack by 20-25 percent, a stroke by 35-40 percent, and heart failure by 50 percent.
Example: RPM Patient Care Pathway for Hypertensive Patients
- Physician (or ordering provider) orders RPM with a blood pressure cuff for patient with hypertension
- A care team member is assigned to the patient and educates the patient on the benefits of RPM as well as the requirements based on the provider’s order, for example, daily readings one hour after blood pressure medication taken in the morning
- Care team member/ordering provider and the patient discuss treatment plan and goals
- Care team monitors patient blood pressure readings daily including regular communications by text, phone, and/or video
- Care team member provides ongoing education about what causes hypertension and how to manage it
- Care team members receive automatic notifications of elevated readings and communicate with patients to understand potential causes of high blood pressure reading (stress, diet, alcohol, smoking, lack of exercise, etc.).
- Elevated readings are escalated to physician as needed
This process not only ensures that the hypertensive patient is being checked on every day, it provides ongoing accountability for the patient to be involved in their healthcare and make smart lifestyle choices. For example, most hypertensive patients probably know that choosing an apple for a snack is a better choice than a bag of potato chips. Without RPM, a patient may choose the chips because they prefer chips. However, if they know a care team member is going to be calling them that day and asking about what they ate, they might choose the apple instead as they feel a sense of responsibility and accountability to the clinical staff member that they have likely developed an ongoing relationship with.
Like hypertension, congestive heart failure can be quite manageable with the right treatment plan. Research has demonstrated that RPM can reduce heart failure hospitalizations.
- Over 6 million people have Congestive Heart Failure (CHF)
- Over 500,000 new CHF cases are diagnosed each year
- CHF is one of the most common causes of hospitalization for those over 65 years old
- CHF contributed to nearly 400,000 deaths in 2018
A primary component of heart failure management is encouraging patients to weigh themselves daily. Sudden increases in weight can indicate an increase in fluid buildup, which is a sign of worsening heart failure. However, many patients may find it difficult to stay disciplined not just in the daily weigh-ins, but also in writing down their weight and looking for meaningful changes.
Instead of placing the burden of tracking and trending weigh-ins on patients, an RPM program provides a connected weight scale that automatically sends data to the provider. The clinical staff at the office has the knowledge and expertise to understand and analyze the data. They can proactively reach out to heart failure patients and adjust medications as needed to decrease preventable heart failure admissions. RPM for heart failure works in the same way as hypertension but a scale or a combination of scale and blood pressure cuff are utilized.
Systematic reviews have demonstrated that heart failure patients participating in RPM programs benefit from a reduction in mortality and higher satisfaction with their care. Additional studies have also shown a reduction in re-hospitalization rates for heart failure patients.
Diabetes and Prediabetes
More than 29 million people, or approximately one in every 10 Americans, have diabetes. Poorly controlled diabetes can lead to a variety of medical issues, including heart disease, foot problems from poor circulation, kidney disease, and eye problems.
Most patients with diabetes are already used to measuring their blood sugar levels with a glucometer. Like the other conditions we covered, one benefit of RPM is the collaboration with medical staff that has the right clinical expertise to consistently and effectively analyze trends in blood sugar readings and the potential impact on medications and dosage. In addition, RPM provides increased accountability for making smart diet and lifestyle choices through ongoing communication and education with a care team member.
A study of low-income adults in rural communities with poorly controlled type 2 diabetes demonstrated that remote patient monitoring led to better outcomes, including not only significantly lower HbA1c levels, but also increased engagement with their treatment plans.
The RPM system allowed the nurses to monitor the patient’s at-home, daily blood glucose and blood pressure readings. The nurse could also consult with the patient’s physicians about the readings and adjust medication dosage when needed.
Patient engagement in making meaningful lifestyle changes has been a long-standing challenge with diabetic patients. RPM allows both patients and their providers to better visualize and understand blood sugar control trends and proactively prevent devastating long-term complications of the disease. It also facilitates ongoing and regular communication between patients and clinical staff which leads to real-time education opportunities about lifestyle changes that have significant impacts.
Approximately 1 in 3 Americans has prediabetes. RPM can actually help with diabetes prevention through use of a connected weight scale. Like diabetes, the weight scale facilitates patient engagement and allows providers to deliver real-time patient education in a timely and meaningful fashion.
When paired alongside other commonly prescribed diabetes prevention measures, RPM has proven to be effective at helping patients to decrease their weight, increase their physical activity, and reduce patient medical costs.
Chronic Obstructive Pulmonary Disease (COPD) and Other Respiratory Diseases
A pulse oximeter device measures oxygen saturation, a critical vital sign indicating an exacerbation of COPD. Studies demonstrate that COPD patients find RPM easy to use and are willing to use their connected pulse oximeters throughout the pulmonary rehabilitation process.
Another study showed that RPM helped patients feel more confidence in managing their COPD. By recognizing the signs of a potential COPD exacerbation, patients can begin early treatment, minimizing the impact of exacerbation.
Chronic Kidney Disease
About 37 million adults in the U.S. have Chronic Kidney Disease (CKD). As many as 90 percent of adults with CKD do not even know they have it and approximately 40 percent of adults have severe CKD and do not know it.
Patients with CKD can lower their risk for kidney failure by:
- Monitoring and managing blood pressure
- Monitoring and managing blood sugar
- Maintaining a healthy weight to prevent further kidney damage
- Make lifestyle changes that contribute to healthy kidney function
Several RPM devices, including a blood pressure cuff, glucometer, and/or weight scale, in combination with regular patient education and coaching, can assist with all of those risks. End-stage kidney disease is often shared with other comorbidities, such as diabetes and hypertension, that can be effectively managed through RPM.
In addition, studies show a positive impact of RPM on at-home dialysis patients, including peritoneal dialysis. Home dialysis is often underutilized because of patient education and adherence, which RPM could help overcome. RPM enables care team members to communicate with patients on a regular basis outside of a clinic, which can be critical for successful at-home dialysis.
More than 40 percent of adults in the U.S. are considered obese. Obesity increases the risk for many chronic conditions and adverse outcomes, including heart disease, stroke, type 2 diabetes and certain types of cancer.
Losing and maintaining weight loss is obviously no easy task. The success of Remote Patient Monitoring in helping patients lose weight goes far beyond daily weigh-ins and trending data. Because every RPM patient is assigned to a Care Team Member, there is a real person on the other side of the scale to help with accountability and real-time education. That ongoing communication and coaching provide the needed support to make the right diet and exercise choices in real-time.
Studies demonstrate that patients who use connected weight scales daily achieve greater weight loss. In addition, phone-based coaching and videoconferencing can be useful tools for supporting significant weight loss among obese patients.
Beyond Chronic Conditions
Since RPM does not require a specific diagnosis, there are multiple applications for RPM. Beyond the conditions listed above, RPM could be used for:
- Post-acute care. RPM could be used to monitor a patient after an acute episode, surgery, or hospitalization.
- Behavioral health. RPM can be used to track patients’ emotional, behavioral, and physical well-being to provide a better care plan.
- Maternity care monitoring. RPM can provide benefits for patients with gestational hypertension or gestational diabetes. These conditions require constant monitoring and RPM can enable this with fewer office visits.
- Pain management.
- Medication management. Patients failing to take their medications as directed leads to approximately 125,000 deaths and up to 25 percent of all U.S. hospitalizations. While not currently reimbursed by CMS, smart pill caps connected to RPM software with reminders to take medication have the potential to have a significant impact on medication adherence.
The RPM Reimbursement landscape will likely continue to evolve, paving the way for more patients with varying conditions to benefit from RPM. CMS is proposing Remote Therapeutic Monitoring codes for 2022, which could include reimbursement for monitoring of “non-physiologic data” such as “musculoskeletal system status, respiratory system status, therapy (medication) adherence, and therapy (medication) response” as well as pain.
Common RPM Devices
With an understanding of what conditions can be monitored with RPM, we can now look at various RPM devices.
- Blood pressure monitor. Also known as a blood pressure cuff, this device is placed on a patient’s arm, filled with air, and then squeezed to measure the patient’s heart rate and blood flow. Blood pressure readings can be helpful in monitoring patients with a variety of conditions, including hypertension, heart failure, and diabetes.
- Glucose monitor. Also known as a glucometer, this device uses a drop of blood to measure blood sugar. Glucometers are often used by patients with diabetes multiple times throughout the day to measure the impact of diet and exercise on blood sugar levels.
- Electrocardiography (ECG) devices. These devices record electrical impulses from a patient’s heart to catch signs of cardiac abnormalities and can be helpful in monitoring heart failure patients.
- Pulse oximeter. These clips are attached to a patient’s finger to measure blood oxygen levels in patients with COPD or other respiratory illnesses.
- Weight scale. A scale has multiple RPM applications. For heart failure patients, a sudden increase in weight can indicate fluid build-up which can be a sign of worsening heart failure. Scales can also be used for obese, diabetic, and pre-diabetic patients to manage weight and assist in weight loss.
- Thermometers. Thermometers measure a patient’s body temperature. Elevated body temperature, or fevers, can be a sign of COVID-19, the flu, or other infections.
- Wearables. Activity trackers, typically worn as watches, can measure steps, heart rate, and sleep and provide insight into a patient’s daily activity levels.
Patients with some conditions, such as diabetes and heart failure, could benefit from multiple devices. However, many insurances, including Medicare, do not reimburse for additional devices and it could add additional burden to the patient (and staff) so it’s important to select the right device(s) for each patient. Will they adhere to readings with two devices or would it make more sense to start with one and then potentially add a second?
Cellular vs. Bluetooth Devices
Beyond choosing what kind of devices you need based on the conditions you are monitoring, you need to select the specific brands and types of devices that you will use. Ease of use is a critical consideration when selecting devices, especially if your patient population includes older, less tech-savvy patients. Some devices are as simple as pushing a single button to transmit data, whereas others on the market involve a complex 17-step setup process.
Devices, apps, and downloads may seem overly complicated to many patients. The more complex a device seems, the less likely a non-tech-savvy patient will be to use it. Bluetooth devices in particular can require more setup steps, a pairing process, and occasional app updates.
Fortunately, there are RPM-compatible, cellular devices available that are incredibly easy to use. For example, with a cellular blood pressure cuff, a patient simply pushes one button to take the reading and it automatically transmits to your RPM software. If a patient has an RPM-enabled, cellular scale, they step on and off the scale just like they would with a regular scale. No additional steps or connections are needed.
Bluetooth devices do provide the patient with more information and the ability to track their data over time, but they are much more complex to use. Bluetooth devices can be a great fit for tech-savvy patients who want to be more engaged with their own health information on an app.
Connectivity is also another consideration in choosing cellular vs. Bluetooth, particularly in rural areas. Bluetooth devices require Wi-Fi, whereas cellular devices require cell service. Most cellular devices are cell phone tower agnostic, meaning if you have a cell phone that works with any carrier, your cellular RPM device will work. Some remote areas may have great Wi-Fi and poor cell service, while other rural areas can be the opposite.
Stage 3: Preparing to Launch a Successful RPM Program
After identifying conditions and devices for the RPM program, there are still additional decisions that need to be made. This stage of the playbook will provide guidance on several key planning and execution steps, including:
- Defining Your Goals
- Engaging the Team
- Choosing How to Staff for Monitoring
- Selecting an RPM Partner
Defining Your Goals
Let’s start with goals. For any program to be successful, you need to define what success will look like. You should understand WHY you want to launch an RPM program. A few questions that can help you define your goals include:
- What are your clinical objectives for implementing RPM?
- What specific patient populations are you looking to treat?
- How many patients will your RPM program serve and how will you grow to that number?
- How would you like RPM to impact patient engagement?
- What are your financial goals with RPM?
- Are you willing and able to allocate the right internal resources to make RPM a success?
Knowing where you want to go will help you assess if the program is successful and can help guide how you adjust processes to support your goals.
Examples of specific clinical goals could include:
- Decreasing hospitalizations
- Decreasing < 30-day readmissions
- Decreasing ER usage
- Lowering or maintaining blood pressure levels to control hypertension
- Lowering A1C levels for diabetic patients
Financial goals will likely link to reimbursement requirements and could include:
- Number of new active patients added per week
- Number of new active patients added in 3, 6 and 12 months
- Percent of RPM patients taking 16 days of readings or more every 30 days
- Percent of RPM patients receiving 20 minutes of care team member time per month AND one live, synchronous interaction
Additional goals could include:
- Increasing patient satisfaction
- Increasing patient engagement
- Increasing staff satisfaction
- Utilizing RPM to meet requirements for government programs such as QPP, MIPS or APM
Engaging the Team
Having a distinct list of goals will help with getting buy-in from your team. A thriving RPM program will involve many different players in your office so it’s critical to have their support upfront. The time investment from various staff members is not insignificant, so it’s important that everyone understands why the practice is launching an RPM program and aligns with the goals.
Important roles and functions for RPM include:
- Executive Champion: Creates the business case for RPM, defines the goals for RPM, and drives organizational buy-in for the goals.
- RPM Lead: The go-to person who leads the day-to-day efforts for RPM. The RPM Lead (can be the same person as the Exec Champion) will be the primary contact interfacing with your RPM partner and for questions within the office. They will manage the roles and responsibilities and ensure there is adequate staff time for patient identification, onboarding, monitoring, and billing. In partnership with the RPM vendor, they will track performance against new patient growth and engagement goals and work with the Executive Champion to make changes to the program as needed. They will also be responsible for ongoing device ordering as the program grows.
- Ordering Providers: RPM must be ordered by a Physician or Qualified Healthcare Provider. Every ordering provider must understand the practice’s criteria for RPM and what needs to be included in an RPM order (frequency of readings, specific instructions such as taking readings after medications, thresholds for normal readings, etc.). Providers must also be in alignment with the clinical staff on escalation processes for when a patient needs additional treatment.
- Clinical Staff: Clinical staff, including nurses and medical assistants, will be responsible for the day-to-day execution of the program, including patient onboarding and patient monitoring. A clinical staff member can also be the RPM Lead. This is truly the heart of the RPM program and it’s critical that sufficient staff hours be allocated to RPM.
- Front Office Staff: Can assist with multiple responsibilities to reduce the workload on clinical staff, including patient scheduling, patient consents, data entry, prepping devices, etc.
- Billing: RPM should result in a new, profitable revenue stream for a practice. RPM software should make it very easy to collect the information you need for effective billing with sufficient documentation in case of an audit. However, it is ultimately up to the practice to determine what they bill for and a strong understanding of the RPM CPT® billing codes and requirements is important.
Choosing How to Staff for Monitoring
As you work through the process of engaging the team, you will likely begin to understand how much time your team has to dedicate to RPM. This leads to the next critical decision of how to resource the staffing hours required for RPM monitoring.
RPM is NOT a "set it and forget it" program. You need staff to interact with your RPM patients on a daily basis. Adding RPM responsibilities to your already stretched-thin staff is likely going to lead to insufficient engagement.
How much staff time do you need? The amount of patient engagement time needed can vary significantly based on each patient’s treatment plan and goals. Let’s assume your practice wants to bill for both the 99454 CPT® code for 16-days of readings and the 99457 CPT® code for 20-minutes of engagement time for most patients. The acuity of patients and the experience of your staff will also factor into how many patients they can monitor. In our experience, the range is pretty wide and one full-time dedicated clinical staff member can monitor somewhere between 150 – 200 patients. Smaller RPM programs can dedicate a partial FTE, but it’s critical that you allocate the right number of hours for RPM.
The following chart is an example of a staffing calculator. It estimates the number of Care Team Member (CTM) hours you will need per week as your RPM program grows, based on 150 patients per full-time CTM. Your CTMs may be able to monitor more or less depending on the needs of your patient population.
Sample RPM Staffing Estimates
|# of RPM Patients||20||50||100|
|Est. CTM Hours||5.3||13.3||26.7|
|Needed per Week|
If you don't have sufficient staff available for the additional workload, there are additional options. The cost of a new hire can be easily justified with the increased RPM reimbursement.
Another solution is partner-managed monitoring, which means you can choose an RPM vendor that provides monitoring services. A strong RPM vendor will provide RNs that follow your clinical protocols and act as an extension of your own staff.
Key considerations when evaluating monitoring services should include:
- What are the experience levels and credentials of their clinical staff?
- What are their processes for getting to know your practice and matching your workflows?
- How will they handle patient escalations?
- How will they communicate with you about non-urgent patient updates?
- How successful are they in engaging patients? This can be measured by patient satisfaction as well as their ability to hit the thresholds for billing the CPT® codes.
- How do they bill you for monitoring services?
- Can they manage your current patient volume and expected growth?
The advantages and disadvantages of self-monitoring versus using a partner-managed are explained below.
An important consideration to remember is that even with partner-managed monitoring, your practice will still need to have the resources available to manage patient escalations and patient interventions, such as changes to medication and treatment plans, as needed.
While partner-managed monitoring may cost more in the short-term than self-monitoring, the long-term returns as shown in the two graphs below are generally higher because:
- Partner-managed staff has dedicated time to enable a higher percentage of patients hitting the threshold to bill multiple CPT® codes
- Partner-managed staff can more consistently hit the thresholds for billing multiple CPT® codes each month as your RPM partner will cover vacations, sick leave, and staff is never pulled into other priorities. This leads to more predictable reimbursement.
- Partner staff can more easily flex to accommodate any RPM patient volume. Whether you are starting small or large, growing quickly or slowly, partner-managed is essentially just-in-time staffing.
- Your clinical staff can continue to focus on in-office visits and other practice priorities as many RPM operational challenges such as hiring and training staff, managing staff schedules, and priorities for RPM are removed.
Selecting the Right RPM Partner
If you already know how you will be staffing RPM, that can impact your selection of an RPM partner. Selecting the right RPM software is important, but your RPM vendor should offer a true partnership that extends well beyond software.
Key RPM vendor software features to look for include:
- Tracks patient adherence – can you easily see how many days of readings a patient has taken?
- Provides multiple tools to increase patient engagement
- Automated reminders
- Patient communication tools, including click to call, text, or video chat directly from the software
- Automated time tracking
- Real-time notifications on out of threshold readings
- Tracks Care Team Member engagement
- Easy-to-use – will your staff members be able to learn this quickly and feel comfortable using the software
- Intuitive workflows to help your staff prioritize their time such as easy sort and filter options
- Regulatory compliance – software tracks time, generates billing reports, and provides an audit trail
Beyond the software, another point of evaluation should include:
- Dedicated implementation and client support – do they provide a dedicated Client Success Manager that is committed to helping you grow and optimize your RPM program or just a collection of do-it-yourself articles online
- Experience helping hundreds of practices launch RPM programs so you skip the trial and error and learn from proven best practices
- Availability of additional services such as Outsourced Monitoring, Eligibility Verification, and EHR Integration
- Device selection that fits with your patient population, such as cellular devices
- Ongoing expertise in interpreting CMS changes to billing code requirements
Stage 4: Identifying and Onboarding Patients
At this point, many key RPM decisions have been made and your team should be fully engaged and ready to launch the RPM program. This stage of the playbook will cover:
- Creating a list of RPM-Eligible Patients
- Strategies for Patient Onboarding
- How to Conduct a Successful RPM Onboarding Event
- Using Telehealth for Onboarding
- Educating Patients about RPM
Creating a List of RPM-Eligible Patients
You already selected the conditions you wanted to monitor and purchased devices from your chosen vendor in Stage 2. Now it’s time to generate a list of specific patient names for RPM. There are a few more things to keep in mind while creating this list:
- Do you want to monitor all patients with those conditions or focus on the more acute cases?
- What percent of your patient population has RPM insurance coverage?
- Medicare covers RPM
- Commercial insurance varies but is increasing. Many RPM providers have an Eligibility Verification service
- Medicaid varies by state
- Who might be most at-risk based on socioeconomic factors?
- What is your staffing capacity to onboard and monitor patients?
Your EHR can be a great resource for compiling a list of RPM-eligible patients.
Strategies for Patient Onboarding
We recommend onboarding patients in two phases:
- Initial Onboarding Event - An RPM Onboarding Event entails assigning dedicated rooms and staff for RPM Onboarding Appointments for one or more days. This enables you to ramp your RPM program quickly and allow more patients to start benefiting from RPM immediately.
- Ongoing RPM Appointments – RPM staff should identify RPM-eligible patients scheduled for appointments on a daily or weekly basis. By reviewing upcoming schedules in advance, you can flag RPM-eligible patients and ensure that an order is placed in their chart in advance. Patients can have an onboarding visit with your clinical staff after the Ordering Provider recommends RPM or possibly even before if there is a wait to see the provider.
Once you have a list of RPM-eligible patients, it is time to determine your pace for patient onboarding. Patient volume should reflect both potentially eligible patients as well as your staff’s capacity. If you are outsourcing monitoring, your partner should be able to flex staffing to meet your patient volume.
We find it’s often easiest to set realistic small targets – how many new RPM patients per week – and that can lead to longer-term patient onboarding goals.
- Initial Onboarding Event
- How many staff, rooms, and hours can you dedicate to RPM onboarding?
- Estimate 20 min per appointment
- Weekly New RPM Patients
- How many total patients do you see per week?
- Approximately what percent meet your RPM criteria?
- 3, 6, and 12 Month New RPM Patients
- Calculate based on Onboarding Event and Weekly Goals
- Factor in Patient Churn (7 percent per month is industry average)
- Total Potential Patients
- Ultimate goal based on number of total patients in your practice that meet your RPM criteria
How to Conduct a Successful RPM Onboarding Event
An RPM Onboarding Event is a great way to launch your program, but requires advance planning. The onboarding appointment is your primary opportunity to set expectations with the patient. Unfortunately, if not done well, it’s easy for a patient to walk away confused or not understanding the importance of taking regular readings. If onboarding does not adequately engage the patient, patient turnover can be high. This can be easily avoided by always thinking about the 5E’s when discussing RPM with a patient and their caregivers.
- Educating a patient about a disease and ways to improve their condition
- Engaging a patient in their health care gives them a feeling of involvement
- Equipping the patient with appropriate devices and expectations on using the device
- Encourage the patient regularly with phones calls, video chats, text messages
- Empower the patient to become self-driven in the improvement of their health
With the 5E’s in mind, the following steps, and guidance from your RPM vendor, can help ensure you have a successful onboarding event.
- Schedule RPM appointments
- Assign roles and responsibilities
- Plan event logistics
- Conduct RPM appointments
Step 1: Schedule RPM Appointments
After your patient list is generated and prioritized, it’s time to start calling patients. Your RPM partner should be able to provide a suggested script for your staff to use when calling patients to schedule 20-minute RPM appointments. The script should explain the benefits of RPM and includes answers to potential objections. Scheduling can be done by clinical or admin staff.
Step 2: Assign Roles and Responsibilities
Some onboarding steps, such as entering patient information and verifying insurance coverage, can be automated in advance of the Onboarding Event. However, it is critical to allocate sufficient time for the staff to:
- Collect patient consent. Can be verbal or written. We recommend this be done by front desk staff during check-in.
- Obtain the RPM Order. Ideally, all orders are submitted by Ordering Provider in the EHR before the appointment and should include frequency of readings and any specific timing instructions, such as, before or after medications.
- Prepare for the RPM Event. Admin or clinical staff.
- Conduct the RPM Appointment. Strongly recommend dedicating the clinical staff’s entire day (one clinical staff member per room being used for RPM appointments) to RPM and find coverage for their other routine responsibilities during the Onboarding Event.
Step 3: Plan Event Logistics
The more setup that is completed in advance of the Onboarding Event, the smoother things will go. Recommended planning and preparation steps include:
- Completing software training for all staff involved in onboarding
- Assign room(s) for RPM specific appointments
- Stock the room(s) with devices and patient education materials (ask your RPM vendor)
- Prepare the devices (install batteries, loosen cuffs, add label with office phone number)
- Confirm the order for RPM is placed for every patient’s chart with specific instructions
- Upload all patient information into the RPM software
- Pre-assign a specific device to each patient and link the device to the patient in the RPM software
Step 4: Conduct RPM Appointments
During the Onboarding Event, it’s essential to maintain strong communication between the front desk and the RPM staff. While we recommend scheduling RPM-specific appointments during the Onboarding Event, we know some regularly scheduled patients will also be RPM eligible. It’s important to ensure those patients are going to the RPM rooms before or after their provider visit.
Your RPM partner should be able to provide a detailed checklist to ensure you are not missing any steps in the onboarding process and the patient leaves feeling confident about how to use their device and is engaged with RPM.
Once you have successfully onboarded a patient, it’s imperative to keep the momentum going and immediately begin monitoring. Outreach to patients should begin within 24 hours of their onboarding appointment.
Can I use Telehealth for RPM Onboarding?
Some patients may not be able or willing to schedule another visit specifically for RPM onboarding. One option is to wait until their next regularly scheduled appointment. Alternatively, you can ship a device to a patient (some vendors even offer drop shipment directly to a patient) and schedule a telehealth visit for the onboarding appointment. If possible, we highly recommend a video appointment so that you can replicate the above steps with the 5E’s similar to an in-person visit. We recommend confirming with a patient’s insurance to ensure coverage of telehealth visits.
RPM will likely not be successful if the device shows up at a patient’s house with no instructions or communication. The closer a virtual appointment can be to an in-person appointment in terms of coaching the patient how to use the device, ensuring they have taken their first reading, explaining the details of the provider’s order for frequency of readings, setting expectations for ongoing communication, the more likely the patient will be fully engaged with RPM.
Educating Patients about RPM
Remote Patient Monitoring is a value-added service for your patients and should be positioned as such. With the pandemic accelerating the trends towards telehealth, many consumers are already aware of RPM. According to a 2021 survey of 300 consumers, 65-70 percent said they would be willing to participate in an RPM program, especially for monitoring chronic diseases. While the survey was small, it indicates that many patients do see the benefits, including:
- 43 percent said RPM had greater convenience
- 39 percent said RPM was efficient
- 37 percent stated RPM enabled more control over personal health
- 36 percent said RPM provided accuracy or peace of mind
Providers should leverage this growing acceptance of telehealth to promote RPM to all of their eligible patients. There is still a significant number of patients that do not know what RPM is or may not understand entirely what it entails.
We highly recommend promoting the benefits of RPM in any and all communications with your patients, such as your office waiting room, website, Facebook page, newsletters/e-newsletters, etc. Your RPM partner should be able to provide you with flyers for your office as well as recommendations on where and how to promote RPM.
Furthermore, providers must also be aware that 25 percent of people are comfortable switching providers, which means you could lose patients if you are not offering telehealth and remote patient monitoring. RPM can and should be promoted as a competitive differentiator for your practice.
Continuous marketing and promotion of RPM will continue to fuel the growth and clinical benefits of your program and help with ongoing patient onboarding.
Stage 5: Monitoring Patients
Once patients have been successfully set up on the RPM program, monitoring should begin immediately. This is the truly exciting stage of RPM where patients and practices will reap the clinical benefits of proactive treatment to chronic and acute conditions. This stage of the playbook will cover:
- Why is monitoring important?
- Who can monitor patients?
- What does day-to-day monitoring include?
- Escalation Criteria
- Potential Staffing Challenges and Alternatives
Why is Monitoring Important?
To reap the clinical benefits of RPM, patients must take regular readings and clinical staff must use that data to monitor and treat patients. The effectiveness of your program – and the reason Medicare reimburses based on readings and clinical staff minutes – is completely reliant on how your clinical staff engages and interacts with patients.
Who Can Monitor Patients?
While RPM must be ordered by a Qualified Healthcare Professional (QHCP), CMS does allow for other licensed, clinical staff to conduct the monitoring. This includes nursing staff and medical assistants that are state-licensed. Regulations can vary by state, so it’s always wise to check with your local MAC office. Clerical or administrative staff can not conduct monitoring for reimbursement. Physicians and ordering providers can also conduct monitoring and they are reimbursed at a higher rate with a separate CPT® code.
Qualified Professionals by Monitoring Role
|Ordering RPM||RPM Onboarding and Monitoring|
|Qualified Professionals||MD, DO, NP, PA||Ordering providers, nurses (RNs, LPNs, LVNs), MAs (in most states)*|
|Not Qualified||Non-licensed clinical staff or admin staff|
*According to CMS rules, monitoring conducted by Medical Assistants (MA) must be done under the direct supervision of the ordering physician. This means that a remote MA or MA in a different location from the provider may not be able to provide monitoring, although we recommend checking with your state licensure rules.
What Does Day-to-Day Monitoring Include?
For staff that are new to RPM, a checklist of tasks can be helpful to ensure high levels of adherence and engagement. Your RPM software should easily support these workflows.
- Have I responded to all notifications and called all patients with readings outside of their target range?
- What patients require escalation and further treatment?
- Have I called all patients that have not submitted a reading in the last two days? What can I say that would encourage them to take a reading?
- Have I led at upcoming appointments and flagged potential RPM patients?
- Have I welcomed all new patients or their caregivers to the platform and encouraged them to communicate with me regularly?
- Have I sent positive reinforcement to patients taking readings consistently and managing their condition well?
- Have I manually added all time that I spent outside of the system for all patients? This includes discussing a patient’s case with other care team members, documentation in the EHR, phone or video calls outside the RPM portal, etc.
- Have I attempted to call each patient for monthly education? Remember, one live, two-way, interactive phone call or video call is required with each patient per month (we recommend weekly call attempts to ensure you connect with each patient).
- Have I checked all my assigned patients to ensure they are on target for 16 days of readings per month? What can I do differently to encourage more readings?
- Have I checked that all my assigned patients are on target for 20 minutes of caregiver time? If not, how can I increase engagement with them? Are there opportunities for additional patient education? Have I updated their treatment plan and goals?
- Have I had at least one live, two-way, interactive phone call or video call with each patient?
- Request call or video call with any patient* that had less than 12 days of readings in a month or two consecutive months of 12-15 readings.
- Identify unengaged patients for potential unenrollment. What other tactics can be employed to get them re-engaged?
Ongoing Patient Education
RPM provides a unique opportunity to provide patient education and coaching at the point when it matters most – immediately after an elevated reading. We strongly recommend having a standard set of patient education materials, including a set of questions to ask patients when calling about an elevated reading. These questions can point out to the patient where they have deviated from their treatment plan and lifestyle goals in a non-threatening way.
For example, a set of questions for a patient with hypertension after submitting an elevated reading could include:
- Is there anything unusual in your daily routine today that could explain your elevated blood pressure?
- Did you take your blood pressure reading before taking your blood pressure medication or any other medication?
- Did you take your blood pressure after activity?
- Are you feeling any stress, anxiety, or pain?
- Have you eaten more salty foods than usual (including adding salt to your food, restaurant food, frozen food, and canned food)?
- How much alcohol have you consumed?
- Have you been smoking? More than usual?
- Have you used an anti-inflammatory drug, such as ibuprofen? How much?
- Are you on any new medications, including prescription, over the counter or illicit drugs (decongestants, steroids, stimulants)?
- Have you gained weight (if not using an RPM scale)?
- How much physical exercise have you had? Any changes to your regular exercise program?
In many cases, a nursing professional can successfully troubleshoot an elevated reading by discussing potential root causes with the patient and requesting a new reading. However, there will certainly be instances when elevated readings indicate a potential crisis situation or the need for medication adjustment. In these cases, the clinical staff member should involve a physician or ordering provider.
The most successful RPM programs have pre-established escalation criteria so there is no doubt when clinical staff needs to get additional team members involved.
Escalation criteria should include:
- Thresholds for a single reading to be escalated
- Trends in readings that require escalation
- Timeframe for responding to alerts and escalations
- Primary and secondary points of contact for escalations
Another point of consideration is the level of experience and credentials of the staff conducting the clinical monitoring. A best practice is to have RNs monitor as they have the education and experience to complete a full nursing assessment and triage appropriately. This can minimize the number of required escalations to an ordering provider. That said, many practices choose to use a Medical Assistant for monitoring and that may necessitate an interim level of escalation to an RN.
Potential Staffing Challenges and Alternatives
If you opted for self-monitoring and are now finding it more challenging than you anticipated, you are not alone. Staffing can be one of the biggest challenges for practices launching and trying to grow RPM programs. RPM is effective because clinical staff can provide timely interventions and education and that requires staff time. In fact, we can’t say this often enough - adding RPM responsibilities to your already stretched-thin staff is likely going to lead to insufficient engagement.
If you don't have sufficient staff for the additional workload, there are two options. The cost of a new hire can be easily justified with the increased RPM reimbursement. Your RPM partner should be able to help you conduct an ROI analysis for hiring a new staff member based on the additional reimbursement you can expect and the added salary costs.
Another solution, as we discussed in Stage 3, is to consider outsourcing monitoring to your RPM vendor. A strong RPM vendor will provide RNs that:
- Allow you to scale your RPM program without worrying about staffing calculators and resources needed for any number of patients
- Prevent false escalations as experienced RNs can work independently, present solutions, and maximize the efficiency of physician involvement
- Prioritize your time for in-person patient visits
- Reduce administrative burden
- Protect your practice from potential audits as medical assistants need to operate under the direct supervision of the ordering provider
Because RNs in a partner-managed monitoring service are typically only delivering RPM services (vs. juggling RPM, in-person visits, and other office duties), they can create an amazing patient-centered experience through personalized outreach, education, and engagement.
If your program is struggling to get the results you expected, you might want to consider partner-managed monitoring. As a point of reference, here are some results that you could expect from Optimize Health’s monitoring service:
- An average of 40+ minutes of patient engagement per month
- Reduced readmission rates, including some that are two times lower than the national average:
- Diabetes patients: 5.9 percent readmission rate
- Heart Failure patients: 0 percent readmission rate
- Hypertension patients:
- 0.26 percent at 30 days
- 7.96 percent at 90 days
Stage 6: Billing for RPM Services
Your team has put in the hard work of planning for and implementing an RPM program. RPM patients are being onboarded and monitored. You have invested significant time in delivering RPM services and should be reimbursed for your efforts. This stage of the playbook will cover what you need to know to do exactly that:
- Overview of RPM CPT® Codes
- CPT® Code 99453 - What you need to know
- CPT® Code 99454 - What you need to know
- CPT® Code 99457 - What you need to know
- CPT® Code 99458 - What you need to know
- CPT® Code 99091 - What you need to know
- Average National Medicare Payment Amounts
- Commercial Insurance
Overview of RPM CPT® Codes
While most practices pursue RPM primarily for the clinical benefits and improved outcomes for their patients, it can also be quite profitable. To effectively bill for RPM reimbursement, it’s critical to have a strong understanding of the CMS CPT® codes and RPM software that allows you to easily capture and report on the information you need to bill for each of the reimbursement codes.
There are five remote monitoring CPT® codes, with most practices choosing to focus on the first four. More detailed requirements are below, but here is a snapshot:
|CMS CPT® CODE||OVERVIEW|
|CPT® Code 99453||One-time patient set-up code|
|CPT® Code 99454||Patient adherence, i.e., the patient is actively using their device and taking readings|
|CPT® Code 99457||Patient engagement and ongoing communication and treatment of patient from clinical staff|
|CPT® Code 99458||Additional patient engagement time|
|CPT® Code 99091||Patient engagement and treatment conducted by physician or QHCP|
Let’s dive into the specific requirements for each code and how the information can be collected to ensure accurate billing and an audit trail, if needed.
CPT® Code 99453 - What You Need to Know
The 99453 code covers the initial onboarding, set-up, and patient education for RPM. This code can only be billed once per episode per care. While this code covers the initial set-up, you must have 16 days of monitoring before you can bill. Your RPM software should automatically track the number of days since setup so you know when to bill 99453. Additional requirements to bill 99453 include:
- Must be ordered by a physician or Qualified Healthcare Provider (QHCP) with patient consent
- Can only be billed once per episode of care even if more than one RPM device is utilized
- Requires data transmission. If the patient has been set up and 16 days have passed, but no readings have been taken, you cannot bill 99453. We recommend taking the first reading at the point of setup so there is data transmission.
CPT® Code 99454 - What You Need to Know
The 99454 code ensures patient adherence with taking readings. CMS specific language is “Device(s) supply with daily recording(s) or programmed alert transmission, each 30 days.” This means you can bill 99454 every 30 days provided there have been 16 days of readings (not 16 or more total readings) within those 30 days. Your RPM software should make it very easy to track days of readings.
Additional requirements to bill 99454 include:
- Device must be ordered by a physician or other qualified healthcare provider
- Device must be defined as a medical device by the FDA
- Can only be billed once per 30 days regardless of the number devices used
During the public COVID-19 health emergency (PHE), patients with a suspected or confirmed diagnosis of COVID-19, are only required to take two days of readings.
CPT® Code 99457 - What You Need to Know
The 99457 code reimburses a practice for the time clinical staff spends monitoring and communicating with RPM patients. CMS-specific language for 99457 is “The first 20 minutes of interactive communication with patient or caregiver from clinical staff, QHCP, or MD in a calendar month.” This code can be billed once per month. Your RPM software should automatically track time spent in the system and communicate with patients (with the ability to manually add time).
Care team member time spent on the following activities would count towards the 20 minutes:
- Reviewing readings and analyzing patterns in the data
- Any communication with the patient including text, voice, and video, including patient education
- Discussing the patient’s data and treatment plan with another provider
- Escalating a reading to a physician or other provider
- Making adjustments to treatment plans, medication, etc.
- Charting notes in the RPM and/or EHR systems
- You cannot apply minutes spent on the same activity to RPM and another billable activity such as CCM or an office visit
Additional requirements to bill 99457 include:
- At least one live synchronous (audio or video) communication per month (Back and forth texts or voicemail is not sufficient. It must be live, two-way communication.)
- Time is performed by clinical staff, QHCP, or physician. “Clinical Staff” is defined by a state’s Scope of Practice laws, but typically includes licensed, clinical staff such as nurses or medical assistants.
- Can be submitted with or without 16 days of transmissions or days of monitoring.
CPT® Code 99458 - What You Need to Know
The 99458 code allows a practice to bill additional 20-minute increments spent with RPM patients beyond the initial 20 minutes. You can only bill 99458 as an add-on to 99457 but you can bill more than one 99458 per month. CMS has not limited the number of times 99458 can be billed but it could vary by state and locality. We recommend checking with your local MAC office. Like 99457, 99458 can be submitted with or without billing 99453. The same activities that contribute towards minutes for CPT® code 99457 also count for CPT® code 99458.
CPT® Code 99091 - What You Need to Know
CPT® Code 99091 is typically used less frequently. This code should only be used if a physician or QHCP is providing the RPM monitoring instead of clinical staff, i.e., nursing staff and medical assistants. 99091 does reimburse at a higher rate than 99457 but it requires 30 minutes of time that is performed directly by the practitioner rather than clinical staff. You can NOT bill 99091 with 99457 or 99458.
Average National Medicare Payment Amounts
According to the 2021 Medicare Physician Fee Schedule, the general national payment amount for each of the CMS CPT® codes is:
- 99453: $19
- 99454: $63
- 99457: $51
- 99458: $41
- 99091: $57
While specific reimbursement will vary by geographic area, if a patient is billing 99454 and 99457 every month, the average reimbursement could be $1200-1700 per patient per year.
While Medicare pioneered the reimbursement standards for Remote Patient Monitoring, commercial insurance carriers are quickly including coverage for RPM services. While many states have begun requiring commercial insurers to cover telemedicine, a large number of commercial payers have voluntarily increased coverage of telemedicine, including RPM, during the pandemic. With the benefits and associated cost-savings of RPM so clearly documented, this expanded coverage certainly appears here to stay.
Many RPM providers offer eligibility verification so you can quickly identify patients with RPM coverage without spending unnecessary time on pre-authorizations. In fact, Optimize Health’s eligibility verification service shows an average of 60 percent of a typical practice’s commercial population has RPM coverage.
With eligibility verification, you can expand the clinical impact of RPM to more patients who would benefit from real-time monitoring, without any administrative burden.
- Minimize denials or delays
- Fast-track patient activation
- Diversify and expand your revenue across CMS and commercial payers
- Accurately forecast your RPM program revenue
Preventive care shouldn’t be limited to a specific age group, and it doesn’t have to be anymore.
Stage 7: Managing and Growing your RPM Program
As with any new initiative, the “launch” is just the starting point. Hopefully, you set strong goals in Stage 3 and it’s important to measure your progress against those goals. By regularly tracking and assessing your performance, you can make the adjustments that you need for continued RPM success. The final stage of the playbook covers:
- Managing new patient growth
- Managing patient engagement
- Managing clinical goals
Managing New Patient Growth
For the first few months, we recommend closely watching the number of new patients added per week relative to your goals. It’s important to make sure the entire team gets into a rhythm of ongoing identification and onboarding of new patients.
If you are not hitting your weekly new patient goal, questions you can ask to find potential improvement opportunities include:
- Is someone in the office proactively identifying and flagging patients at least one day prior to their appointment?
- If not, can you carve out time to look at all upcoming appointments weekly?
- Is the right staff assigned to this task? Could someone else assist? Can other responsibilities be shifted to someone else so there is more time for patient identification?
- Are enough patients meeting your RPM criteria to meet the weekly goal?
- Would it make sense to consider other conditions and devices to include more patients?
- Is Eligibility Verification being used to include commercial patients?
- Does the weekly goal need to be adjusted?
- Once patients are identified, are the ordering providers writing orders before the appointment?
- How is the staff flagging patients to providers? EHR? Notes? Team meeting?
- Is there a better way to flag patients so that providers know they need to write the order?
- Is there a morning or weekly meeting where flagged patients can be discussed with providers and orders written?
- Once orders are written, is the patient completing the onboarding appointment?
- What percent of patients are saying they are not interested in RPM?
- Is the staff – front desk, clinical staff, ordering providers – using the right language to promote the benefits of RPM? Do they have a script to use?
- What and who has been most effective in getting patients to say Yes to RPM?
- Is the front desk and the clinical staff communicating throughout the day to ensure each patient flagged for RPM is completing an RPM onboarding before they leave (either before or after their provider appointment)?
- Is there sufficient clinical staff time to complete the onboarding appointment?
- Are there sufficient devices in stock to complete the onboarding appointment?
Answering these questions can help identify where the potential gap between your goal and performance is for new patients. By looking at numbers weekly, you can ensure that you are finding and resolving bottlenecks quickly. You should also have regular check-ins with your implementation and client success teams with your RPM partner. They have been through hundreds of launches and can help you pinpoint what might not be going right and how to course correct.
Once you have established a strong workflow for ongoing patient onboarding, you can adjust your 3, 6, and 12 month goals accordingly. And start thinking about if and when you want to expand RPM to additional conditions and patient populations. Another conversation that your RPM partner can help with.
Managing Patient Engagement
Beyond new patient growth goals, you should also be working with your RPM partner to set up monthly business reviews around other goals. Your RPM partner should be able to easily pull reports that measure:
- New active patients
- Percent of patients with 16 days of readings per month
- Percent of patients with 20 minutes of engagement time per month
- Percent of patients with 40 minutes of engagement time per month
- Percent of patients with 60 minutes of engagement time per month
- Percent of patients with one live, synchronous call per month
- Percent of patients with 20 minutes of engagement time per month AND one live, synchronous call per month (99457 billing requirements)
- Average engagement minutes per patients
- Number of unenrolled patients
- Total SMS messages sent
- Total phone calls
- Total video calls
These metrics, trended over time, can help you assess the level of engagement of both your patients and care team members. While every practice’s goals are unique, successful RPM programs are typically reaching 70-100 percent on the 99454 and 99457 CPT® code billing requirements (16 days of readings and 20 minutes of engagement time with one live call).
If your patient adherence and engagement is lower than you would like, it’s likely because your staff does not have enough time to invest in the RPM program. A few questions you can ask to determine the best solution:
- Is the monitoring staff completely comfortable with the RPM software? Do they need additional training? Or an easier to use system?
- Have I looked at engagement time by Care Team Member?
- Is there a concern with one team member or all?
- Have I set goals for engagement time by Care Team Member?
- Have I used a staffing calculator to determine how many hours of RPM time my clinical staff needs?
- Does my clinical staff have the required time? If not,
- Can I shift responsibilities to other staff members to make additional time for RPM?
- Am I open to hiring new staff if the increased financial reimbursement more than offsets the cost?
- Am I open to partner-managed monitoring with experienced RNs so I can increase reimbursement while keeping my staff focused on the in-office patient experience?
Managing Clinical Goals
Finally, practices should assess their performance relative to the clinical goals they set in the pre-implementation process. Clinical success can be slower to measure. Be patient, and give RPM at least six months before making any judgments on clinical results.
And share your clinical successes – quantitative or qualitative – with your team. We hear stories from practices all the time about how RPM likely prevented a stroke or hypertensive crisis. These stories are incredibly motivating as they help connect the work associated with RPM with its powerful impact. RPM has the ability to improve the health and quality of life for many of your patients – which is exactly why many members of your team entered the healthcare field!
While the potential for RPM to positively impact our patient’s life is significant, it does require strong leadership, dedicated staff, and careful planning to implement successfully. Whether you are brand new to RPM or trying to re-energize an existing program, we hope this playbook has provided a foundation for understanding everything that is required for a successful launch or re-launch.
At Optimize Health, we believe strongly in the power of RPM to be a critical component in improving patient outcomes while lowering costs. We are always happy to talk to healthcare groups about our services or just answer questions about RPM in general.