Beginning Dec. 1, 2022, EmblemHealth will expand coverage for remote patient monitoring (RPM) during pregnancy and up to 84 days postpartum to further improve and expand access to prenatal and postpartum care for our Medicaid and HARP members. This expansion of coverage includes an additional monthly fee for EmblemHealth providers to cover the cost of RPM devices/equipment.
Billing Guidance
- Current Procedural Terminology (CPT) code "99091" must be billed for the RPM service as per general New York State (NYS) Medicaid telehealth guidance:
- A minimum of 30 minutes per month must be spent collecting and interpreting member RPM data.
- CPT code "99091" may be billed no more than one time per member per month.
- RPM services should be billed on the last day of each month in which RPM is delivered.
- Federally Qualified Health Centers (FQHCs) reimbursed via the federal all-inclusive prospective payment system (PPS) rate are unable to bill for RPM services, as these services are furnished because of an FQHC visit and, therefore, are included in the FQHC PPS rate.
- CPT code "99453" with HD modifier, denoting pregnant/postpartum service, may be billed once per member per pregnancy for the initial set-up of the RPM device/equipment. CPT code "99453" is to be used once per episode of clinical care (the time from service activation of the device/equipment to when the RPM period ends).
- CPT code "99454" with an HD modifier, denoting pregnant/postpartum services, may be billed once per 30-day period when the provider supplies and uses a medical device/equipment to remotely monitor and collect patient-generated health data during the member's pregnancy and/or the post-partum period(s). CPT code "99454" is billed for continuous RPM medical device supply and patient monitoring.
- Billing CPT code "99453" and CPT code "99454" requires usage of a medical device that digitally collects and transmits 16 or more days of data every 30 days.
- CPT code "99454" is billed along with CPT code "99091".
| CPT Code | Description | Fee |
| 99091 | Collection and interpretation of physiologic data [e.g.,electrocardiogram (ECG), blood pressure, glucose monitoring] digitallystored and/or transmitted by the patient and/or caregiver to the physician orother qualified health care professional, qualified by education, training,licensure/regulation (when applicable) requiring a minimum of 30 minutes oftime, each 30 days. | $48.00 |
| 99453+ HD (maternal service) modifier | Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure,pulse oximetry, respiratory flow rate), initial; set-up and patient education onuse of equipment. | $14.85 |
| 99454 + HD (maternal service) modifier | Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Every 30 days when a minimum of 16 days of data is collected withinthe 30-day period. This is a once per 30-day fee regardless of thenumber of devices used to monitor the pregnant/post-partum individual.To be billed with CPT Code "99091 ". | $43.23 |
JP #56547 11/2022
