Reimbursement
Recent changes have greatly expanded reimbursement for telehealth and Remote Patient Monitoring (RPM). In fact, RPM codes are stackable with CCM and Complex CCM codes, many behavioural health codes and other non-face to face reimbursements within a comprehensive program.
Reimbursement Strategies & Sources of Revenue
The cost of the RxPense Hub, Portal or Care Portal can easily be defrayed, in fact may become a revenue generator over time. Most insurers (Private + Public) cover telemedicine and remote patient monitoring for those able to bill Medicare, Medicaid or a traditional Payor like an insurance company. While this source of revenue is currently available in the USA*, the COVID-19 pandemic has opened the eyes of politicians around the world to better ways of interacting and helping patients.
As of August 2021, CMS in the USA has expanded coverage to even more remote monitoring activities. Recent changes have greatly expanded reimbursement for telehealth and remote patient monitoring. The current billing codes allow for a minimal annual revenue of $2,079 per device, when billing only for RPM services. Add on fees for daily patient measurements and telemedicine and not only is the cost of the RxPense solution covered, but you have opened a new, recurring revenue stream to boost your profit.
Explore the table below to determine the appropriate billing codes which may be applicable in your instance. To download the CMS List of Telehealth Services, complete, or this summary table, click on one of the links, below.
* While the RxPense Hub is not available in the USA, we are providing this information to assist with other products as they become available.
New CPT Codes reimburse for Remote Patient Monitoring
CPT 99453
$19 ONE-TIME
initial set-up and training on use of equipment
CPT 99454
$64 MONTHLY
device records data and generates programmed alerts
CPT 99457
$32-$52 MONTHLY
remote monitoring services with 20 min clinician time
Sample Medicare/Medicaid/(Private Payor) Reimbursement Codes for Telehealth and Remote Patient Monitoring*
| Billing Code | What it Covers | Who Can Bill | How Often | What Medicare Pays |
| Telehealth Visits | ||||
| 99202-99205 | Telehealth-enabled office or other visits for new patients |
Medicare Part B Providers or Qualified Health Professionals |
Once | $73.97 – $224.36 |
| 99211-99215 | Telehealth-enabled office or other visits for established patients |
Medicare Part B Providers or Qualified Health Professionals |
No limitation | $23.03 – $183.19 |
| G0425-27 | Telehealth consultations | Medicare Part B Providers or Qualified Health Professionals |
No limitation | $101.19 – $200.29 |
| G0406-08 | Follow-up inpatient telehealth consultations furnished to beneficiaries in a hospital or SNF |
Medicare Part B Providers or Qualified Health Professionals |
No limitation | $38.38 – $103.28 |
| Virtual Check-ins | ||||
| G2010 G2012 |
A brief (5-10 minutes) check via telephone or other telecommunications device to decide whether an office visit or other service is needed. It may also include a remote evaluation of recorded video and/or images submitted by an established patient. |
Medicare Part B Providers or Qualified Health Professionals |
No limitation | $12.21 $14.66 |
| e-visits | ||||
| 99421-423 | Patient-initiated communications between an established patient and their provider through a HIPAA-compliant secure platform. |
Medicare Part B Providers or Qualified Health Professionals that can bill for E/M services. |
Once during a 7-day period |
$15.00 – $47.46 |
| Remote Patient Monitoring | ||||
| 99091 | The collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional. In this instance, a QHP is qualified by education, training, licensure/regulation (when applicable). The code requires a minimum of 30 minutes of interpretation and review. |
To bill for CPT Code 99091, the initial provider service must occur in the physician’s office or other applicable sites. Additionally, only a physician or QHP may perform these services, distinguishing it significantly from 99457, in which a clinical staff member can provide services “incident to.” |
Once in a 30-day billing period. |
$56.88 |
| 99453 | The initial set-up of devices, training, and education on the use of monitoring equipment and any services needed to enroll the patient on-site. |
Not specified; not required to be clinical staff (Practice Expense Only Code) |
Once per patient, only first month of reading for 99454 |
$19.19 |
| 99454 | The supply and provisioning of devices used for RPM programs. |
Not specified; not required to be clinical staff (Practice Expense Only Code) |
Once in a 30-day billing period; required 16 days of readings |
$63.16 |
| 99457 | The remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP, or other clinical staff must provide RPM treatment management services for at least 20 minutes per month. |
Those in indirect general supervision of clinical staff |
Once per month | $50.94 |
| 99458 | Each additional 20 minutes of remote monitoring and treatment management services provided. |
Those in indirect general supervision of clinical staff |
Once per month | $41.17 |
| Chronic Care Management | ||||
|
99490 99487 |
The first full 20 minutes of non-complex Chronic Care Management of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements: • Multiple (2 or more) chronic conditions expected to last at least 12 months or until the death of the patient; • Chronic conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline; • Comprehensive care plan established, implemented, revised, or monitored. |
Medicare Part B Providers or Qualified Health Professionals |
Once per month | $91.77 |
| 99487 | The first 60 minutes of clinical staff or QHP or provider time for moderately or highly complex CCM. | Medicare Part B Providers or Qualified Health Professionals | Once per month | $41.17 |
| 99489 | An additional 30 minutes of time spent in the same billing cycle as 99487 with high or moderate complexity patients who require more time. | Medicare Part B Providers or Qualified Health Professionals |
Once per month | $43.97 |
| Principal Care Management | ||||
| G2064 | An interaction between a physician or non- physician practitioner with a patient with one chronic disease or high-risk condition lasting at least 30 minutes per calendar month. | Medicare Part B Providers or Qualified Health Professionals |
Once per month | $90.37 |
| G2065 | An interaction between clinical staff with a patient with one chronic disease or high-risk condition lasting at least 30 minutes per calendar month. | Medicare Part B Providers or Qualified Health Professionals |
Once per month | $38.73 |
| Transition Care Management | ||||
| 99495 | Transitional Care Management services, including interactive contact with the moderately complex patient within two days of discharge, with a face-to-face visit within 14 days of discharge. |
Medicare Part B Providers or Qualified Health Professionals |
Once per discharge | $207.96 |
| 99496 | Extra care incentives for highly complex patients with interactive contact within two days of discharge for TCM services, with a face- to-face visit within seven (7) days of discharge. |
Medicare Part B Providers or Qualified Health Professionals |
Once per discharge | $281.59 |
Community and Waiver Programs to help you Purchase an RxPense
The provinces and territories provide coverage to certain people (e.g., seniors, children and low-income residents) for health services that are not generally covered under the publicly funded health care system. These supplementary health benefits often include prescription drugs outside hospitals, dental care, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), and the services of other health professionals such as physiotherapists. The level of coverage varies across the country.
As noted earlier, those who do not qualify for supplementary benefits under government plans pay for these services through out-of-pocket payments or through private health insurance plans. Many Canadians, either through their employers or on their own, are covered by private health insurance and the level of coverage provided varies according to the plan purchased.
- Health Organizations
- Canadian Agency for Drugs and Technologies in Health (CADTH)
- Canadian Institute for Health Information (CIHI)
- Canada Health Infoway
- Canadian Health Services Research Foundation (CHSRF)
- Canadian Partnership Against Cancer Corporation (CPACC)
- Canadian Patient Safety Institute (CPSI)
- Mental Health Commission of Canada
- Provinces and Territories
- Newfoundland and Labrador – Department of Health and Community Services
- Prince Edward Island – Department of Health and Wellness
- Nova Scotia – Department of Health and Wellness
- New Brunswick – Department of Health
- Quebec – Ministry of Health and Social Services
- Ontario – Ministry of Health and Long-Term Care
- Manitoba – Manitoba Health
- Saskatchewan – Saskatchewan Health
- Alberta – Alberta Health and Wellness
- British Columbia – Ministry of Health Services
- Yukon – Yukon Health and Social Services
- Northwest Territories – Department of Health and Social Services
- Nunavut – Department of Health and Social Services