On November 2, 2023, the Facilities for Medicare & Medicaid Companies (CMS) finalized new insurance policies associated to distant physiologic monitoring (RPM) and distant therapeutic monitoring (RTM) companies reimbursed underneath the Medicare program. 

The steerage revealed within the 2024 Doctor Charge Schedule ultimate rule (2024 Last Rule) addresses billing eventualities and requests for clarifications on the suitable use of those distant monitoring codes. The 2024 Last Rule clarifies CMS’ place on the way it interprets sure necessities for these companies. CMS rejected among the proposals contained within the 2024 Proposed Rule and constructed upon earlier RPM and RTM steerage. 

Under are the important thing takeaways RPM and RTM suppliers should know concerning the 2024 Last Rule.

RPM and RTM Clarifications

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

In prior rulemaking, RPM companies have been restricted to “established sufferers.” Traditionally, with a purpose to grow to be a longtime affected person for Medicare RPM functions, a affected person usually would bear a brand new affected person Analysis and Administration (E/M), or comparable service, throughout which the billing practitioner collects related details about the affected person after which establishes a remedy plan. In the course of the Public Well being Emergency (PHE), CMS waived the established affected person requirement. When the PHE expired in Could 2023, RPM companies have been as soon as once more restricted to established sufferers. These sufferers who obtained distant monitoring companies in the course of the PHE however who didn’t bear an preliminary new affected person examination might be deemed “established sufferers” underneath CMS’ latest rule clarification.

In sum, Medicare sufferers who obtained preliminary RPM companies in the course of the PHE might be thought of established sufferers (i.e., sufferers who started receiving RPM companies in the course of the PHE might be “grandfathered” in). These sufferers who obtain preliminary RPM companies after Could 11, 2023 (the top of the PHE) might want to grow to be a longtime affected person earlier than enrolling in a Medicare RPM companies program.

RTM Does Not Comprise an “Established Affected person” Requirement

Whereas RPM companies require a longtime affected person relationship previous to billing RPM codes, RTM companies don’t have any such categorical requirement (no less than not but). We highlighted this distinction in our prior protection and inspired stakeholders to submit feedback and ask CMS to substantiate whether or not or not the “established affected person” requirement applies to each RPM and RTM, or simply RPM.

CMS confirmed within the 2024 Last Rule, “RPM, not RTM, companies require a longtime affected person relationship after the top of the PHE.” Regardless of the dearth of an categorical requirement, CMS expressed its perception that RTM companies can be furnished to a affected person solely after a remedy plan has been established (and presumably after the billing practitioner carried out an preliminary interplay analysis with the affected person).

Below present RTM guidelines, the failure to conduct an preliminary affected person analysis and create an “established affected person” relationship is probably not a per se deviation of RTM billing necessities, nevertheless it stays doable that failing to finish this preliminary interplay and create a remedy plan might expose RTM practitioners to post-payment audits primarily based on Medicare’s “cheap and needed” normal. CMS stated it should make clear this coverage in future rulemaking.

Practitioners Should Acquire at Least 16 Days of Knowledge Per 30-Day Interval

Within the 2024 Last Rule, CMS clarified which distant monitoring codes require no less than 16 days of information assortment in a 30-day interval, and which codes don’t have any such requirement. Prior CMS commentary indicated the RPM and RTM set-up and system codes (CPT codes 99453, 98976, 99454, 98977, and 98978) required no less than 16 days of information assortment. Nonetheless, there was ambiguity as as to if or not the 16-day requirement utilized to the 4 remedy administration codes (CPT codes 99457, 99458, 98980, and 98981). We highlighted this ambiguity in our earlier weblog submit and inspired stakeholders to submit feedback advocating for larger flexibility on the 16-day requirement.

Within the 2024 Last Rule, CMS wrote:

We word that within the CY 2024 PFS proposed rule, we inadvertently listed all the RTM codes (88 FR 53204) in our dialogue of those companies and had made a basic assertion concerning the applicability of the 16-day information assortment requirement. We wish to supply clarification that the 16-day information assortment requirement doesn’t apply to CPT codes 99457, 99458, 98980, and 98981. These CPT codes are remedy administration codes that account for time spent in a calendar month and don’t require 16 days of information assortment in a 30-day interval.

This represents the primary time CMS expressly said in revealed steerage how the 16-day information assortment requirement doesn’t apply to the RPM and RTM remedy administration codes (CPT codes 99457, 99458, 98980, and 98981).

Solely One Practitioner Can Invoice Medicare for RPM/RTM Companies

In a given 30-day interval, just one practitioner can invoice RPM (CPT codes 99453 and 99454) or RTM (CPT codes 98976, 98977, 98980, and 98981), and solely when no less than 16 days of information has been collected on no less than one medical system. “Even when a number of medical units are supplied to a affected person,” CMS defined, “the companies related to all of the medical units may be billed by just one practitioner, solely as soon as per affected person, per 30-day interval and solely when no less than 16 days of information have been collected.” Furthermore, remotely-monitored month-to-month companies needs to be billed solely when cheap and needed, in line with prior CMS steerage.

When reiterating that just one practitioner can invoice these codes, CMS didn’t expressly checklist the 2 codes for RPM remedy administration companies (CPT codes 99457 and 99458), though CMS did checklist the 2 codes for RTM remedy administration companies. In future rulemaking, stakeholders ought to think about asking CMS to make clear whether or not or not a number of practitioners can invoice CPT codes 99457 and 99458 for a similar affected person in the identical 30-day interval. Till then, whereas it arguably is probably not a per se deviation of RPM billing necessities to have a number of practitioners concurrently invoice Medicare for a similar affected person, it stays doable that such billing might expose RPM practitioners to assert denials or post-payment audits primarily based on Medicare’s “cheap and needed” normal.

Use of RPM/RTM with Different Companies

Practitioners are permitted to invoice Medicare for RPM or RTM (however not each) concurrently with the next care administration companies for a similar affected person as long as the effort and time is just not counted twice: Power Care Administration (CCM), Transitional Care Administration (TCM), Behavioral Well being Integration (BHI), Principal Care Administration (PCM), and Power Ache Administration (CPM). By permitting this concurrent billing, CMS intends to afford practitioners most flexibility when choosing the precise mixture of care administration companies for sufferers, whereas nonetheless guarding towards fraud, waste, and abuse.

This restriction is just not restricted to Medicare. The 2023 CPT Codebook Steering explains that CPT code 98980/98981 (RTM remedy administration) can’t be reported together with CPT codes 99457/99458 (RPM remedy administration).

Billing RPM or RTM Throughout World Surgical procedure Durations

When a billing practitioner furnishes a process or surgical procedure topic to a worldwide billing interval (the place the practitioner receives a lump cost masking the post-surgical follow-up companies inside the worldwide interval), that practitioner can’t invoice Medicare for RPM or RTM companies supplied to the affected person throughout that world interval. It is because the worldwide billing cost obtained by the practitioner covers these post-surgical follow-up companies in the course of the interval. This coverage was clarified within the 2024 Last Rule.

Nonetheless, the coverage that prohibits RPM or RTM companies being furnished in the course of the world interval solely applies to billing practitioners who’re receiving the worldwide service cost. Practitioners, similar to therapists, who will not be receiving a worldwide service cost as a result of they didn’t furnish the worldwide process, are permitted to furnish RPM or RTM companies throughout a worldwide interval. Offering RTM or RPM companies in the course of the world interval is permitted if the practitioner is just not receiving world service cost as a result of they didn’t furnish the worldwide process. This implies, for instance, a health care provider can carry out surgical procedure on a affected person underneath world billing, and a bodily therapist can enroll the affected person within the therapist’s RTM program for post-surgery rehab and monitoring.

Correspondingly, CMS defined how, for a affected person who already is receiving RPM or RTM companies throughout a worldwide interval, a practitioner might furnish RPM or RTM companies (however not each) to the affected person, and Medicare can pay the practitioner individually for the RPM or RTM, as long as the distant monitoring companies are unrelated to the prognosis for which the world 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 take care of the world process – which means that the distant monitoring companies tackle an underlying situation that’s not linked to the world process or service.

FQHCs and RHCs Could Obtain Separate Reimbursement for RPM and RTM Companies

Traditionally, Federally Certified Well being Facilities (FQHCs) and Rural Well being Clinics (RHCs) weren’t approved to individually invoice for RPM and RTM companies, and cost was made by way of an all-inclusive price moderately than separate reimbursement. Starting January 1, 2024, FQHCs and RHCs might now individually invoice Medicare for RPM and RTM. They accomplish that utilizing the overall care administration code (HCPCS code G0511) on an FQHC or RHC declare kind. The RPM/RTM companies have to be medically cheap and needed, meet all of the coding necessities, and can’t be duplicative of companies already paid for underneath the overall care administration code for an episode of care in a given calendar month.

RHCs and FQHCs might invoice HCPCS code G0511 a number of occasions in a calendar month, in accordance with CMS’ commentary, supplied all necessities are met and useful resource prices will not be counted greater than as soon as. CMS will submit the ultimate 2024 cost price for the overall care administration HCPCS code G0511 on the RHC and FQHC heart web sites (which may be accessed right here and right here).

Bodily Therapists and Occupational Therapists can Invoice RTM for Assistants Below Basic Supervision

Bodily therapists (PTs) and occupational therapists (OTs) can present and invoice Medicare for RTM companies. Nonetheless, Medicare laws for PTs and OTs in non-public follow (PTPPs and OTPPs) required all bodily and occupational remedy companies in that setting to be carried out by, or underneath the direct supervision of, the PT or OT. Requiring direct supervision ranges renders it tough for PTPPs and OTPPs to invoice for RTM companies carried out by assistants (PTAs and OTAs) underneath their supervision.

Starting January 1, 2024, Medicare will solely require basic supervision for PTPPs and OTPPs to invoice for RTM companies furnished by their PTAs and OTAs. This variation is achieved by way of the institution of an RTM particular basic supervision provision in 42 C.F.R. § 410.59(a)(3)(ii) and (c)(2) and 42 C.F.R. § 410.60(a)(3)(ii) and (c)(2). One caveat to this transformation: Medicare will proceed to require PTPPs and OTPPs to instantly supervise their employed PTs and OTs if the PT or OT being supervised is just not individually enrolled in Medicare.

RPM is Not Included within the Definition of Major Care Companies for MSSP