Remote Therapeutic Monitoring in the 2022 MPFS: How CMS Can (and Should) Get it Right
Nov. 3, 2021 UPDATE: The Final 2022 MPFS has arrived! Check out our latest post on New Reimbursement for Remote Patient Monitoring
In mid-July, we posted an article on the new Remote Therapeutic Monitoring (“RTM”) CPT codes recognized by the Centers for Medicare and Medicaid Services (“CMS”) in its Proposed Medicare Physician Fee Schedule for 2022 (the “Proposed Rule”). While we celebrated these new codes as another step forward for expanding virtual care services, we noted some confusion and raised several outstanding questions about how the RTM codes will be used. CMS recognized many of the questions we raised in that article in the Proposed Rule and asked for stakeholder feedback “on how [they] might remedy the issues related to the RTM code construction” to allow for a more practical implementation of RTM when the codes are finalized.
Based on our extensive work with remote patient monitoring and care management digital health companies along with the physician practices who use the existing care management codes – including Remote Patient Monitoring (“RPM”), Chronic Care Management, Principal Care Management, and Behavioral Health Integration – that improve patient outcomes and lower the overall cost of care, this article is Nixon Gwilt Law’s take on the approach that we believe CMS should follow in improving and finalizing the RTM codes and associated reimbursement.
CMS should fully align the services and code structures for Remote Patient Monitoring and Remote Therapeutic Monitoring
In the Proposed Rule, CMS notes that “the services and code structure of RTM resemble those of RPM.” This resemblance reflects the expressed desire of stakeholders to achieve the following two goals:
Expand the types of patient data that can be captured and utilized for remote monitoring and care management
Expand the types of practitioners who can order and bill for remote monitoring of patient data and associated care management services
CMS and the American Medical Association’s CPT Committee (charged with establishing new CPT codes) significantly moved the needle on the first goal simply by introducing the concept of “Remote Therapeutic Monitoring.” In doing so, they recognized that there is an important category of patient data that does not necessarily fit the definition of “physiologic data” described in the Remote Physiologic Monitoring code set introduced in 2019. As articulated by CMS in its Proposed Rule, examples of “therapeutic data” include pain levels, medication adherence, and therapy adherence as recorded or reported by the patient via a medical device. Practitioner experience and clinical evidence support the notion that monitoring therapeutic data and incorporating that data as part of care/treatment management services improves patient outcomes and reduces the overall cost of care.
CMS and the CPT Committee also made important strides towards expanding the types of practitioners who can order and bill for care management services involving monitoring of patient data – with some small complications to be ironed out. By making the right changes to align the code structures for RTM and RPM in the Final 2022 MPFS (which should be issued in November), CMS can achieve these two important and integrally related goals that will increase access to virtual care management services. Let’s take a closer look at what we think those changes should look like.
CMS should clarify that the RTM CPT codes, as currently proposed, DO allow therapists and other QHCPs who can independently bill Medicare to order and bill for RTM.
The new RTM codes created by the CPT Committee are located in the Medicine (often referred to as the “general medicine”) section of the CPT manual and are available to Qualified Health Care Practitioners (“QHCPs”) who are not able to independently order and bill for Evaluation and Management (“E/M”) services. This means that QHCPs such as physical therapists, occupational therapists, clinical psychologists, registered dieticians, and other practitioners can order and bill for RTM under the codes as currently proposed.
CMS should further clarify that the RTM CPT codes, as currently proposed, DO NOT allow incident-to billing of clinical staff time under the general supervision of physicians, Nurse Practitioners, Physician Assistants, or QHCPs who order RTM.
As discussed above, the proposed RTM codes are Medicine codes and do not include clinical staff time in the code descriptors. CMS also rightfully points out that only E/M services codes – NOT Medicine codes – may be designated as “care management services” that allow for clinical staff time to be counted toward the relevant CPT Code’s time requirement when provided under the general supervision of the billing practitioner.
This means that proposed General Medicine CPT codes 989X4 (Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes) and 989X5 (Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes) require that a physician/NPP/QHCP personally spend 20 minutes of time monitoring and interacting with patient data. While some RTM use cases will have the bulk of the data monitoring time actually performed by the billing QHCP, we know from past lessons learned that the same does NOT hold true for physicians and NPPs.
The first Remote Patient Monitoring code eligible for standalone reimbursement, CPT Code 99091, was introduced in 2018 and required 30 minutes of monitoring/analysis time in a 30-day period by the billing physician/NPP/QHCP. CMS expected significant adoption and utilization of CPT Code 99091 as a means of identifying and intervening in patient problems early. However, low utilization data reflected physician and NPP feedback that they did not have capacity to spend 30 minutes of time per month interacting with each patient’s data. This left many patients who stood to benefit from RPM out of the picture. Instead, physicians/NPPs wanted RPM codes that allowed them to leverage clinical staff time spent on data monitoring “incident to” physician/NPP services (under general supervision), where the physician/NPP would be brought in when clinical staff identifies a potential problem indicated by patient data and escalates for the appropriate intervention. CMS and the CPT Committee acknowledged this feedback and introduced in the 2019 MPFS the much more practical set of RPM codes that exist today – CPT codes 99453, 99454, 99457 and, in 2020, 99458. CMS further designated these E/M codes as “care management services” to allow for clinical staff time to be billed incident-to the ordering physician/NPP under general supervision. CMS needs to develop a coding structure in alignment with RPM that allows for billing practitioners to leverage clinical staff under general supervision in the Final Rule to avoid excluding valuable use cases for RTM.
So – what’s the best way to achieve the goals of expanding the types of patient data utilized for remote monitoring/care management AND expanding the types of practitioners who can order and bill for remote monitoring/care management services?
CMS should fully align the services and code structures for RPM and RTM by keeping the RTM GM codes as proposed and also creating a temporary code set of E/M HCPCS G-codes for RTM that mirrors the current RPM E/M CPT code set, designating these temporary codes as care management services subject to general supervision when ordered by a physician/NPP.
Per the Medicare Claims Processing Manual, CMS has the authority to establish temporary HCPCS G-codes for items or services. CMS should therefore establish temporary E/M G-codes for RTM with code descriptors as follows:
Remote therapeutic monitoring (e.g. respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment (cross-walked to RPM CPT code 99453)
Remote therapeutic monitoring (e.g. respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g. daily) recording(s) and/or programmed alert(s)/transmission, each 30 days (cross-walked to RPM CPT code 99454)
Remote therapeutic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the month; first 20 minutes (cross-walked to RPM CPT code 99457)
Remote therapeutic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the month; each additional 20 minutes (cross-walked to RPM CPT code 99458)
In addition, CMS should fully align the services and code structures for RPM and RTM by creating a temporary code set of Medicine HCPCS G-codes for RPM that mirrors the current RTM Medicine CPT code set, thereby also allowing RPM to be ordered and billed by Qualified Health Care Professionals eligible to bill Medicine codes.
CMS should create temporary Medicine G-codes for RPM with code descriptors as follows:
Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate) by qualified nonphysician health care professional, initial; set-up and patient education on use of equipment (cross-walked to proposed RTM Medicine CPT code 989X1)
Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate) by qualified nonphysician health care professional, initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days (cross-walked to temporary HCPCS G-Code for supply of system-agnostic device(s) for RTM – see below)
Remote physiologic monitoring treatment management services by qualified nonphysician health care professional in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes (cross-walked to proposed RTM Medicine CPT code 989X4)
Remote physiologic monitoring treatment management services by qualified nonphysician health care professional in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (cross-walked to proposed RTM Medicine CPT code 989X5)
In addition to authority under the Medicare Claims Processing Manual, there is recent and related precedent where CMS has created temporary Medicine codes allowing QHCPs to order and bill for virtual care services. In the 2020 MPFS, CMS introduced E/M CPT codes 99421-99423 for e-Visits, billable by physicians/NPPs. In a 2020 Interim Rule, CMS created temporary HCPCS G2061-G2063 allowing QHCPs to order and bill for e-Visits. In the 2021 MPFS, CMS replaced the temporary HCPCS G codes with Medicine CPT codes 98970-98972, making permanent the ability of QHCPs to order and bill e-Visits.
Further, CMS should create a temporary Medicine HCPCS G-Code for supply of a system-agnostic device(s) for RTM.
In the Proposed Rule, CMS introduced two device-related CPT codes for supply of RTM devices. Unfortunately, the proposed codes are limited to musculoskeletal devices and respiratory devices, excluding clinically valuable devices that monitor medication adherence, pain, mood, therapy response, and other relevant non-physiologic patient data that is useful for monitoring, for example, cardiac, diabetic, or behavioral health patients. Designating a system-agnostic device CPT code for use with RTM is necessary to capture these important therapeutic monitoring use cases that CMS already acknowledged in the Proposed Rule. CMS should therefore introduce a temporary Medicine HCPCS G-Code in the Final Rule that simply omits the specific reference to musculoskeletal or respiratory system included in the code descriptors for the currently proposed CPT device codes 989X2 and 989X3 as follows:
Remote therapeutic monitoring (e.g., system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s), each 30 days
As it suggests in the Proposed Rule, CMS should value codes for RTM at parity with the currently existing RPM codes
The RTM codes – both the currently proposed codes and the temporary codes that we advocate establishing above – should be valued at parity with the RPM codes. CMS notes in its Proposed Rule that “the RTM codes reflect similar staff and physician work, although the specific equipment used is different.” Valuing the codes at parity, whether performed by a physician, non-physician practitioner, or QHCP – reflects the better patient outcomes and reduced overall cost of care that CMS aims to achieve.
We believe that incorporating the above changes into the Final 2022 Medicare Physician Fee Schedule will achieve the desired goals of expanding the types of relevant patient data that can be monitored, expanding the types of practitioners able to order and bill for Remote Therapeutic Monitoring and Remote Physiologic Monitoring, and improving patient outcomes while reducing the long-term cost of care.
If you don’t have the resources, expertise, or time to submit stakeholder feedback to CMS before the deadline of September 13, then we can help.
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Special thanks to Nixon Gwilt Law attorneys (and RPM /RTM rockstars) Kaitlyn O’Connor and Casey Papp for their invaluable assistance with this article, and thank you to the NGL Virtual Care team — Faisal Khan, Reema Taneja, and Ashleigh Giovannini — for their service to so many amazing virtual care companies and practices.