99474
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.18
Facility
$8.02
Non-Facility
$18.37
Documentation Required
- RPM/SMBP must meet ALL of the following criteria (policy text): 'Prescribed and administered by a board-eligible or board-certified medical provider or subspecialist (e.g., cardiologist, pulmonologist, endocrinologist), nurse practitioner (NP) or physician assistant (PA)).'
- RPM/SMBP must meet ALL of the following criteria (policy text): 'physiologic data are electronically collected and automatically uploaded for analysis and interpretation.'
- RPM/SMBP must meet ALL of the following criteria (policy text): 'intended for the purpose of displaying or analyzing the physiological parameter(s) measured by the device'.
- RPM/SMBP must meet ALL of the following criteria (policy text): 'used for remote communication, counseling and monitoring of acute or chronic health conditions.'
Key Coverage Criteria
- Remote Physiologic Monitoring (RPM) is considered medically necessary for ANY of the following indications: Chronic Obstructive Pulmonary Disease (COPD); Diabetes Mellitus; Gestational Diabetes; Heart Failure; Hypertensive Disorders Of Pregnancy (HDP).
- Self-Measured Blood Pressure (SMBP) monitoring (CPT codes 99473, 99474) is considered medically necessary for the following indications: Hypertension; Hypertensive Disorders Of Pregnancy (HDP).
- RPM CPT/HCPCS/ICD-10 mappings in the policy indicate coverage when billed with relevant diagnoses including diabetes (E08.00-E13.9), heart failure (I50.1-I50.9), COPD (J44.0-J44.9), and multiple pregnancy-related hypertension/diabetes codes (examples: O10.*, O11.*, O13.*, O14.*, O15.*, O16.*, O24.*) when criteria are met.
1 Active Policy
CIGNA-RPM — Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) - (0563)
Related Codes
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