On July 13, the Facilities for Medicare & Medicaid Companies (CMS) launched its annual Proposed Rule updating the Medicare Doctor Payment Schedule (PFS) for calendar 12 months (CY) 2024, which incorporates numerous proposed modifications associated to the availability of distant physiologic monitoring (RPM) and distant therapeutic monitoring (RTM) companies.

The Proposed Rule, if enacted as proposed, will:

1. Make clear stipulations for billing sure RPM and RTM codes;
2. Make clear that Medicare pays individually for RPM and RTM throughout international surgical procedure intervals;
3. Enable separate fee of RPM and RTM for federally certified well being facilities (FQHCs) and rural well being clinics (RHCs);
4. Enable bodily remedy assistants (PTAs) and occupational remedy assistants (OTAs) to offer RTM below the final supervision of bodily therapists (PTs) and occupational therapists (OTs); and
5. Add RPM to the definition of main care companies used for functions of Medicare Shared Financial savings Program (MSSP) beneficiary task.  

Additionally of explicit word, by the 2024 Proposed Rule, CMS is requesting data from stakeholders on numerous RPM/RTM subjects in addition to associated digital therapies, together with digital cognitive behavioral remedy (CBT). 

RPM and RTM Clarifications

RPM Can Solely be Furnished to an “Established Affected person”

Within the 2021 Remaining Rule, CMS said that RPM companies are restricted to “established sufferers.” In help of this place, CMS asserted {that a} doctor who has a longtime relationship with a affected person would seemingly have had a chance to offer a brand new affected person Analysis and Administration (E/M) service. Throughout that new affected person E/M service, the doctor would have collected related affected person historical past and carried out a bodily examination, as applicable. Because of this, the doctor would possess data wanted to know the present medical standing and desires of the affected person previous to ordering RPM companies to gather and analyze the affected person’s physiologic information and to develop a remedy plan. CMS waived the “established affected person” restriction throughout the Public Well being Emergency (PHE) however within the 2021 Remaining Rule, CMS declined to increase such waiver past the PHE. Usually, this can require the practitioner to conduct a brand new affected person E/M service upfront of initiating RPM companies.

Within the 2024 Proposed Rule, CMS gives clarification that sufferers who acquired preliminary distant monitoring companies throughout the PHE are thought of established sufferers.

It’s notable that CMS expressly references solely RPM (and never RTM) when clarifying the requirement that companies could solely be furnished to an “established affected person.” Thus, stakeholders ought to request that CMS make clear whether or not the “established affected person” requirement applies to each RPM and RTM companies.

Requirement to Acquire 16 Days of Knowledge Stays

Within the Proposed Rule, CMS gives clarification that despite the fact that CMS has acquired numerous feedback and inquiries about modifying its minimal information assortment necessities for distant monitoring, as of the tip of the PHE, the 16-day monitoring requirement was reinstated, which means monitoring should happen over a minimum of 16 days of a 30-day interval.

Moreover, it’s notable that CMS expressly lists RTM CPT (Present Procedural Terminology) codes (98976, 98977, 98978, 98980, and 98981) as people who depend upon assortment of no fewer than 16 days of information in a 30-day interval. Final 12 months, in its proposed 2023 Medicare Doctor Payment Schedule, CMS proposed a requirement that a minimum of 16 days of information should be reported throughout a 30-day interval to invoice the RTM skilled codes (CPT codes 98980 and 98981). Nevertheless, CMS in the end didn’t finalize this proposal within the 2023 closing rule. It seems CMS is as soon as once more re-instating this proposal. If this proposed clarification is finalized, the RTM skilled codes couldn’t be used to handle the remedy of a situation if the monitoring companies didn’t embrace a minimum of 16 days of information. Moreover, by particularly referencing solely the RTM codes, CMS doubtlessly introduces uncertainty with respect whether or not it additionally intends these limitations to use to the RPM skilled codes (CPT codes 99457 and 99458).

Since separate funds for RPM and RTM companies have been established, trade stakeholders have advocated in opposition to this 16-day requirement arguing that it’s clinically arbitrary and ignores situations the place a diminished variety of days can be extra clinically applicable.

stakeholders ought to take into account submitting feedback advocating for better flexibility on the 16-days requirement and what nuances apply solely to RTM, solely to RPM, to each units of codes, or solely to a number of the RPM or RTM codes, however not others.

Solely One Practitioner Can Invoice RPM/RTM

Within the 2024 Proposed Rule, CMS reiterates that for both RPM or RTM, just one practitioner can invoice CPT codes 99453 and 99454, or CPT codes 98976, 98977, 98980, and 98981, throughout a 30-day interval and solely when a minimum of 16 days of information have been collected on a minimum of one medical system. “Even when a number of medical units are offered to a affected person,” CMS defined, “the companies related to all of the medical units will be billed by just one practitioner, solely as soon as per affected person, per 30-day interval, and solely when a minimum of 16 days of information have been collected.” CMS additionally reemphasizes that remotely monitored month-to-month companies must be reported solely when fairly mandatory. These ideas are per earlier CMS steerage.

It’s notable that CMS doesn’t expressly record the CPT codes for RPM remedy administration companies (CPT codes 99457, 99458) when reiterating that just one practitioner can invoice these codes. stakeholders ought to take into account requesting CMS make clear whether or not multiple practitioner can invoice CPT codes 99457 and 99458 for a similar affected person in the identical month.

Use of RPM / RTM with Different Companies

CMS reiterates practitioners could invoice RPM or RTM (however not each RPM and RTM) concurrently with the next care administration companies for a similar affected person so long as time or effort should not counted twice: Persistent Care Administration (CCM), Transitional Care Administration (TCM), Behavioral Well being Integration (BHI), Principal Care Administration (PCM), or Persistent Ache Administration (CPM) codes.

CMS additionally references the 2023 CPT Codebook Steerage that “RPM and RTM might not be billed collectively” to make sure that no time is counted twice by billing for concurrent RPM and RTM companies and to clarify that the identical affected person can’t obtain RPM and RTM companies in the identical month. CMS particularly equates a affected person receiving RPM and RTM in the identical month to a supplier billing RPM a number of instances in a single month the place there may be greater than as soon as system, which on this steerage and previous steerage, Medicare has made clear will not be permissible.

Stakeholders who disagree with this place and interpretation ought to search readability from CMS relating to why RPM and RTM being billed concurrently so long as time will not be counted twice is handled any in a different way than billing RPM or RTM with different care administration companies, which is permitted so long as time will not be counted twice. 

Separate Cost of RPM or RTM Throughout International Surgical procedure Intervals

CMS clarifies that the place a affected person receives a process or surgical procedure, and associated companies, that are lined below a fee for a worldwide interval, RPM or RTM (however not each) could also be furnished individually to the affected person and Medicare would pay for the RPM or RTM companies, separate from the worldwide service fee, as long as different necessities for the worldwide service and some other service throughout the international interval are met. Equally, for a affected person who already is receiving RPM or RTM companies throughout a worldwide interval, a practitioner could furnish RPM or RTM companies (however not each) to the affected person, and Medicare pays the practitioner individually for the RPM or RTM, as long as the distant monitoring companies are unrelated to the analysis for which the worldwide process is carried out, and so long as the aim of the distant monitoring addresses an episode of care that’s separate and distinct from the episode of look after the worldwide process – which means that the distant monitoring companies tackle an underlying situation that isn’t linked to the worldwide process or service.

Permitting Separate Reimbursement for RHCs and FQHCs

For a number of years, RPM and RTM codes have been billable by physicians and doctor teams, however FQHCs and RHCs haven’t been approved to invoice individually for these companies. Usually, when these companies are furnished incident to a doctor or different skilled’s service throughout an FQHC or RHC go to, fee is made by the all-inclusive charge.

CMS is proposing allowing FQHCs and RHCs billing RPM/RTM utilizing the final care administration code, Healthcare Widespread Process Coding System (HCPCS) code G0511 on an FQHC or RHC declare type; offered that RPM/RTM companies are medically cheap and mandatory, meet all the necessities, and should not duplicative of companies paid to RHCs and FQHCs below the final care administration code for an episode of care in a given calendar month.

CMS additional proposes to revise the way it calculates the fee quantity for G0511. Presently, CMS makes use of an unweighted common of the assorted codes included inside HCPCS Code G0511. CMS states that as a result of decrease medical depth of RPM and RTM, including the RPM and RTM codes would outcome within the discount of the G0511 fee quantity from a month-to-month charge of $77.94 to a charge of $64.13. CMS proposes as a substitute to make use of a weighted common, which might end in a charge of $72.98 for the mixed code. CMS is particularly in search of touch upon its proposal to revise the fee charge methodology for G0511.

Stakeholders ought to take into account submitting enter referring to how HCPCS Code G0511 might be valued going ahead and requesting clarification on how practitioners ought to deal with medical eventualities the place each RPM/RTM could also be used concurrently with different care administration codes (e.g., CCM).

PTs and OTs Can invoice RTM for PTAs and OTAs below Basic Supervision

In prior rulemaking, CMS clarified that PTs and OTs can present and invoice for RTM companies. Nevertheless, present Medicare rules require all bodily and occupational remedy companies be carried out by, or below the direct supervision of, the PT or OT. Within the Proposed Rule, CMS acknowledges requiring direct supervision makes it troublesome for PTs and OTs to invoice for the RTM companies carried out by the PTAs and OTAs they’re supervising. Because of this, CMS is proposing to ascertain an RTM-specific basic supervision coverage that will enable RTM to be offered by an PTA or OTA below basic supervision of the PT or OT, respectively.

RPM Included in Definition of Major Care Companies for MSSP

CMS proposes so as to add RPM CPT codes 99457 and 99458 to the definition of main care companies used for functions of beneficiary alignment within the MSSP. This may increasingly serve to increase the scope of beneficiaries who obtain RPM and extra precisely assign beneficiaries to Accountable Care Organizations based mostly on who the affected person acquired RPM companies from.

Request for Info on RPM, RTM and Digital Therapies

CMS is in search of data on how distant monitoring companies, resembling RPM and RTM, are utilized in medical observe with a concentrate on digital CBT. Particularly, CMS asks a number of pages of questions associated to the next subjects:

• How practitioners would establish which sufferers would profit from digital therapeutics and the way practitioners would monitor their effectiveness.
• Requirements which were developed to make sure the privateness and safety of digital therapeutics for behavioral well being.
• Efficient fashions for the distribution or supply of digital therapies and greatest practices to help and practice sufferers.
• Which practitioners and auxiliary employees are concerned in furnishing RPM and RTM.
• How information are collected and maintained for recordkeeping and care coordination.
• How an episode of care must be outlined, notably when one affected person could also be receiving concurrent RTM or digital CBT companies from two distinction clinicians engaged in separate episodes of care.
• How permitting a number of, concurrent RTM companies for a person would possibly have an effect on entry to care, affected person prices, high quality, well being fairness, and program integrity.
• The professionals and cons of generic versus particular RTM system codes.
• What proof CMS ought to take into account when figuring out whether or not digital therapeutics are cheap and mandatory.
• What elements of digital therapeutics for behavioral well being must be thought of when figuring out whether or not they match right into a Medicare profit class, and which class must be used.
• If CMS determines that companies match inside an current Medicare profit class, what elements of digital CBT companies must be thought of when figuring out potential fee (together with whether or not these companies are furnished incident to or unbiased of a go to).
• Boundaries to accessing digital CBT for underserved populations and methods to handle these entry boundaries.

Stakeholders with an curiosity in increasing availability and protection for digital therapies, together with software program as a medical system and prescription digital therapeutics ought to take into account commenting on the rule in hopes of increasing future protection for these kinds of companies. 

Make Your Voice Heard

Suppliers, expertise corporations, and digital care entrepreneurs inquisitive about distant monitoring ought to take into account offering feedback to the Proposed Rule. CMS is soliciting feedback on the Proposed Rule till 5:00 p.m. on September 11, 2023. Anybody could submit feedback – anonymously or in any other case – by way of digital submission at https://www.rules.gov/. Alternatively, commenters could submit feedback by mail to:

• Common Mail: Facilities for Medicare & Medicaid Companies, Division of Well being and Human Companies, Consideration: CMS-1784-P, P.O. Field 8016, Baltimore, MD 21244-8016.
• Specific In a single day Mail: Facilities for Medicare & Medicaid Companies, Division of Well being and Human Companies, Consideration: CMS-1784-P, Mail Cease C4-26-05, 7500 Safety Boulevard, Baltimore, MD 21244-1850.

If submitting by way of mail, please remember to enable time for feedback to be acquired earlier than the time limit.

Conclusion

The CMS Proposed Rule advances the flexibility of RPM and RTM companies to drive income and enhance the affected person care expertise. We’ll proceed to watch CMS for any rule modifications or steerage that have an effect on or enhance RPM and RTM alternatives.

For extra data on telemedicine, telehealth, digital care, distant affected person monitoring, digital well being, and different well being improvements, together with the group, publications, and consultant expertise, go to Foley’s Telemedicine & Digital Well being Trade Crew.