1.0 CPT PROCEDURE CODES
99091, 99453, 99454, 99457,
99458
3.0 POLICY
3.1 Medically
necessary RPM services of physiologic parameter(s) including, but
not limited to, weight, blood pressure, pulse oximetry and respiratory
flow rate are covered when:
3.1.1 The beneficiary requires RPM
services of at least 20 minutes of clinical staff time directed
by a TRICARE-authorized provider, per 30-day period; and
3.1.2 The beneficiary
has a comprehensive care plan established, implemented, revised
or monitored; and one of the following criteria are met:
3.1.2.1 The beneficiary has a chronic
condition(s) that is expected to last at least 12 months, or until
death of the beneficiary; or
3.1.2.2 The beneficiary has an acute
condition(s) that place the beneficiary at significant risk of death,
acute exacerbation/decompensation, or functional decline.
3.2 Consistent
with TRICARE’s statutory obligation to reimburse like Medicare where
practicable, the provider shall bill RPM using the codes and definitions
established by Medicare and the Current Procedural Terminology (CPT)/HCPCS
manuals for RPM billing and coding. For example, bills for acute condition
RPM shall include at least 16 days of data (at least two days during
the COVID-19 public health emergency), consistent with the Medicare
FY 2021 Physician Fee Schedule Final Rule, and as updated or modified
by subsequent Medicare guidance or regulation.
3.3 Monitoring
Devices and Equipment
• The
contractor shall ensure only U.S. Food and Drug Administration (FDA)
approved devices and equipment are used in conjunction with medical
necessary RPM, in accordance with Section 201(h) of the Federal
Food and Drug Cosmetic Act (FD&CA).
• The
contractor shall ensure devices and equipment also meet the definition
of Durable Equipment (DE) and/or Durable Medical Equipment (DME).
See
Chapter 8, Section 2.1.
• The
contractor shall not cost-share equipment or supplies, even when
monitored via RPM, which do not meet TRICARE’s definitions of DE
and/or DME. For example, while DHA may cover RPM of weight, along
with other physiologic parameters for the management of a chronic
condition, the weight scale itself is not eligible for cost-sharing
because it does not meet TRICARE’s definition of DE or DME.
3.4 Covered
services include:
• Set-up
and patient/caregiver education on use of equipment (Current Procedural Terminology
(CPT) code 99453);
• Device supplies with daily
recordings/alert transmission, each 30 days (CPT code 99454);
• RPM treatment
management services, TRICARE-authorized provider time per calendar month
requiring interactive communication with the patient/caregiver for
the first 20 minutes (CPT code 99457); and
• The collection
and interpretation of physiologic data digitally stored and/or transmitted
by the patient/caregiver to the TRICARE- authorized provider with
a minimum of 30 minutes of collection and interpretation time each
30 days (CPT code 99091). See
Chapter 7, Section 22.1.
• Remote
assessment of recorded video and/or images submitted (e.g., store
and forward), including interpretation and follow-up with the beneficiary
within 24 hours (HCPCS G2250).
3.5 Cost-Sharing
The
Government considers RPM an ancillary service as defined in TRICARE
Reimbursement Manual (TRM),
Chapter 2, Section 2, paragraph 2.7.4 and
the contractor shall apply appropriate ancillary service cost-shares
and copayments.
4.0 Exclusion
Devices and equipment that
do not meet TRICARE’s definition of DE/DME (i.e., personal computers,
smart phones, tablets, smart watches, non-medical trackers, weight
scale).