Documentation requirements for billing remote patient monitoring?

[Mrsrpc]

Hi all,
I'm new to reimbursement regarding remote patient monitoring (CPT codes: 99453, 99454, 99457, 00458 and 99091). What documentation from the patient record are payers wanting to be included with claim? TIA

 

[TThivierge]

Hi Mrsrpc,
The documentation should start off for the day of treatment the provider verifying that this is the correct patient and getting pt.' s permission to do the telehealth or phone call . All that is typed on top of EHR page/med record. We use CPT 99441-99443 for MD, DO NP and PA. if phone call. If a telehealth video visit we use the Eval Mg 99202-99214 adding modifier 95. The time must be documented on amount time spent talking or doing video telehealth on each day's treatment too. Then documentation should follow as CC or NOC, history, ROS, med history, reason for follow up and medication discussion ,Etc. and description of what discussed or ancillary labs or xrays ordered for pt s future. If the video does not work or pt cannot get it working note this on medical record then phone patient.
I hope this data helps you
Lady T

 

[Mrsrpc]

Hi Mrsrpc,
The documentation should start off for the day of treatment the provider verifying that this is the correct patient and getting pt.' s permission to do the telehealth or phone call . All that is typed on top of EHR page/med record. We use CPT 99441-99443 for MD, DO NP and PA. if phone call. If a telehealth video visit we use the Eval Mg 99202-99214 adding modifier 95. The time must be documented on amount time spent talking or doing video telehealth on each day's treatment too. Then documentation should follow as CC or NOC, history, ROS, med history, reason for follow up and medication discussion ,Etc. and description of what discussed or ancillary labs or xrays ordered for pt s future. If the video does not work or pt cannot get it working note this on medical record then phone patient.
I hope this data helps you
Lady T

Thank you very much! I wasn't

Hi Mrsrpc,
The documentation should start off for the day of treatment the provider verifying that this is the correct patient and getting pt.' s permission to do the telehealth or phone call . All that is typed on top of EHR page/med record. We use CPT 99441-99443 for MD, DO NP and PA. if phone call. If a telehealth video visit we use the Eval Mg 99202-99214 adding modifier 95. The time must be documented on amount time spent talking or doing video telehealth on each day's treatment too. Then documentation should follow as CC or NOC, history, ROS, med history, reason for follow up and medication discussion ,Etc. and description of what discussed or ancillary labs or xrays ordered for pt s future. If the video does not work or pt cannot get it working note this on medical record then phone patient.
I hope this data helps you
Lady T

Also, is there a good reference on the nuances of this topic? For ex. Im
Assuming I can’t use 99454 RPM along with 99202-14. Much appreciated!

 

[TThivierge]

Hi
Per CPT manual on CPT 99454 states must use CPT 94448 if that time is used in discussion with the patient. See pg 53 in the 2022 year CPT manual. My info above is taken from the CMS website on telehealth coding & billing. reference https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pd
Lady T