TRICARE Manuals - Display Chap 2 Sect 8.1 (Change 122, Dec 20, 2023)

Evaluation And Management

Chapter 2

Section 8.1

Remote Physiologic Monitoring (RPM)

Issue Date: July 7, 2021

Authority: 32 CFR 199.4, NDAA FY 2017, Section 718

Revision: C-119, November 1, 2023

1.0 CPT PROCEDURE CODES

99091, 99453, 99454, 99457, 99458

2.0 HCPCS Code

G2250

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

4.1 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).

4.2 Mobile Medical Applications (MMAs) not listed in Chapter 8, Section 2.1, paragraph 3.12.5.

5.0 Effective Date

March 13, 2020.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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