Ernie Posted Fri 22nd of November, 2019 16:28:58 PM
As a background, FirstVitals is a credential provider in the state of HI with all commercial payers including Medicare. We have a PTAN number and can bill Medicare for our services. However, our business model is a physician extender practice where we support primary care practices with our clinical staff of Nurse Practitioners, RNs, certified case managers, pharmacists, etc. We have been billing the provider for our professional services and the practice in turn bills Medicare for reimbursement. Our question surrounds the new CPT codes for Remote Patient Monitoring where FirstVitals will want to bill Medicare instead billing the provider since we will be managing the technology platform and not the provider. The codes in questions are:
• CPT G0506 – Care Plan Development
• CPT 99453 for Remote Patient Monitoring- Initial Set-up
• CPT 99454 for Patient Monitoring – 30 days
Can FirstVitals bill Medicare directly for the above 3 CPT codes instead of billing the provider? More specifically, FirstVitals will perform the following services:
• CPT G0506 – FirstVitals will create the Care Plan for Remote Patient Monitoring.
• CPT 99453 – FirstVitals will set-up the FDA approved devices for remote patient monitoring with the patient
• CPT 99454 – FirstVitals will capture the patient generated health data for monitoring purposes; provide alert notifications to the provider, track time spent by providers, etc. Important to note, the provider will use the FirstVitals monitoring platform for their clinical interventions and will bill under their CPT Code 99457 and 994X0.
Our question is: can FirstVitals bill Medicare directly for these 3 CPT codes since these patients are not our patients but providing a support service to primary care physicians. We can bill Medicare since we have a contract and is currently billing Medicare for other professional services such as diabetic retinal exams and flu vaccinations.
If you would like to get on a call to discuss in further detail, please let me know. Thank you!
Ernie Lee Cell: 808-295-6809
SuperCoder Answered Mon 25th of November, 2019 08:40:04 AM
Thanks for your question.
Code G0506 can be reported only by the billing practitioner. Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.
Codes 99453 and 99454 are used to report remote physiologic monitoring services (eg, weight, blood pressure, pulse oximetry) during a 30-day period. To report 99453, 99454, the device used must be a medical device as defined by the FDA, and the service must be ordered by a physician or other qualified health care professional. Code 99453 may be used to report the set-up and patient education on use of the device(s). Code 99454 may be used to report supply of the device for daily recording or programmed alert transmissions. Codes 99453, 99454 are not reported if monitoring is less than 16 days. Do not report 99453, 99454 when these services are included in other codes for the duration of time of the physiologic monitoring service (eg, 95250 for continuous glucose monitoring requires a minimum of 72 hours of monitoring). These codes may be billed by physician, qualified healthcare professional, or clinical staff.
Only one clinician can furnish and be paid for CCM services during a calendar month. The clinician who is providing the primary care to the patient is the one who can bill.
Per CMS, CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM.
Please feel free to write if you have any question.
Ernie Posted Mon 25th of November, 2019 20:17:11 PM
Thank you for your reply. More specifically, RPM codes, 99453 and 99454, can FirstVitals bill Medicare for these services if we are working under contract with the provider who provides the primary care to the patient? FirstVitals has its own contract with Medicare and can bill directly. The primary care physician will not bill Medicare for these two codes since FirstVitals will be managing the RPM platform on behalf of the provider. We want to eliminate the need to bill the provider and in turn, the provider must bill Medicare. Is it permissible for FirstVitals to bill Medicare if we have a contract with the primary care provider for these RPM services?
SuperCoder Answered Tue 26th of November, 2019 09:17:07 AM
Our experts are working on this. We will get back to you soon. Thanks for your patience.
Ernie Posted Tue 26th of November, 2019 13:53:58 PM
SuperCoder Answered Wed 27th of November, 2019 02:22:31 AM
Thanks for your patience.
Please be informed that there is no clear guidance on this. Unless there is some specific guidance on 99453 and 99454 being billed by the device company, we would say no to billing these directly. We advise you to stick to your current billing model where you bill the physician for your services and leave the Medicare billing to the physician’s office.
Hope this helps.
Ernie Posted Thu 28th of November, 2019 14:52:47 PM
Even though we can bill Medicare directly for services as a Medicare provider?
SuperCoder Answered Fri 29th of November, 2019 02:26:40 AM
Before discussing this again, we would like to know if these are your direct patients or a physician referred to your organization.
Thanks in advance.
Ernie Posted Fri 29th of November, 2019 16:39:41 PM
As a Management Services Organization (MSO) we are contracted to primary care physician practices as physician extenders. These patients are regularly seen by the primary care physician but FirstVitals provide ongoing care management services to the practice's high risk patients.
Would it help if in order for FirstVitals to bill Medicare, the primary practices add FirstVitals as a Rendering Provider in the MAC (Noridian) PECOS account? Based on your last email, it appears what you are saying only patients with regular E&M visits with their provider can bill for RPM services. Other providers such as specialists (Endocrinologists) will be able to bill for RPM even if the patients are attributed to the PCP such as in the case of chronic care management services, correct? We would like to see how FirstVitals as a provider for Medicare can bill for RPM services and not have to bill the PCP since we will be doing all of the data gathering under CPT 99454.
SuperCoder Answered Mon 02nd of December, 2019 02:28:24 AM
We would again suggest you to stick to your current billing model until we get clear guidelines regarding direct billing to Medicare. We will let you know once we get this clear.
Thanks for your patience.