Why Updating your Clearinghouse Data Matters: A Real-World Example Using CPT Code 99458

At Telecare-USA, we often hear from providers who are doing everything right when it comes to patient care and billing—yet still run into denials and claim holds. One recent example highlights just how important it is to make sure your clearinghouse is working with the most up-to-date information.

The Situation: Denials for CPT 99458

A Family Medicine practice actively billing for Remote Patient Monitoring (RPM), noticed that most of their July claims for CPT 99458 (the add-on code for 20-minute increments of RPM management beyond the first 20 minutes) were put on hold and not paid.

Their billing company insisted that Medicare only allows two units of 99458 per month.

But here’s the issue: that information was outdated.

The Update: CMS Changed the Rules

Effective July 1, 2023, the Centers for Medicare & Medicaid Services (CMS) updated the Medically Unlikely Edits (MUEs) for CPT 99458.

Here’s what the official file says:

• CPT Code: 99458
  
  
• MUE Value: 3
  
  
• MUE Adjudication Indicator: 3 (Date of Service Edit: Clinical)
  
  
• MUE Rationale: Clinical: Data
  
  

In plain language: Medicare Part B allows up to three units of 99458 per patient, per month.

If your clearinghouse or billing system is capping this at two units, it means their edit files haven’t been updated with CMS’s latest rules.

Why This Happens

Denials like this usually come down to one of three things:

1. Clearinghouse Logic: The clearinghouse hasn’t updated its MUE data, so it stops or reduces claims before they even reach Medicare.
   
   
2. Payer-Specific Issues: If you’re dealing with Medicare Advantage (Part C) rather than Traditional Medicare (Part B), some plans may apply edits incorrectly—even though they are required to follow CMS policy.
   
   
3. Internal Billing Workflows: Sometimes, billing software applies legacy rules that need to be adjusted manually.
   
   

What You Should Do If This Happens to You

If you or your billing team see denials or holds for 99458 beyond two units, here are steps to take:

• Confirm the Source of the Hold: Was it flagged by the clearinghouse, or denied by the payer?
  
  
• Check the Payer Type: If it’s Medicare Advantage, verify that they’re following CMS Part B guidance. If not, you have grounds for an appeal.
  
  
• Share the CMS File: Provide your clearinghouse or billing vendor with the official CMS Practitioner Services MUE file (July 2023) so they can correct their logic. (Link to CMS archive)
   
• Review Your EOBs: If needed, work with your practice manager or billing staff to pull example Explanation of Benefits (EOBs) for claims that were denied.

Why This Matters to Your Practice

Getting these details wrong doesn’t just create extra administrative work—it directly impacts revenue. For practices using Remote Patient Monitoring as part of chronic care management, an error like this could mean losing reimbursement for 20 minutes of clinical staff time per patient, per month.

That adds up quickly. For a practice with 50 RPM patients, failing to bill the third unit could mean leaving thousands of dollars on the table every month.

Takeaway

Medicare’s rules change often, and even well-meaning billing companies or clearinghouses can lag behind. As a provider or practice manager, it’s essential to:

• Stay current on CMS updates
  
  
• Verify your clearinghouse and billing software are aligned
  
  
• Advocate for appeals when Medicare Advantage plans misapply rules
  
  

At Telecare-USA, we make sure our partners are up-to-date with the latest CMS policies so their claims go through correctly the first time.

Tip: If you’re seeing unusual denials or claims held in review, don’t assume it’s your mistake—sometimes the system itself is behind.

Want to learn more about how our RPM programs protect your practice while delivering real results?

Contact Telecare-USA today to schedule a consultation.

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