On November 2, 2023, the Facilities for Medicare & Medicaid Providers (CMS) finalized new insurance policies associated to distant physiologic monitoring (RPM) and distant therapeutic monitoring (RTM) companies reimbursed beneath the Medicare program.
The steerage revealed within the 2024 Doctor Payment 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.
Beneath 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, to be able to grow to be a longtime affected person for Medicare RPM functions, a affected person sometimes would endure a brand new affected person Analysis and Administration (E/M), or related service, throughout which the billing practitioner collects related details about the affected person after which establishes a therapy plan. In the course of the Public Well being Emergency (PHE), CMS waived the established affected person requirement. When the PHE expired in Might 2023, RPM companies have been as soon as once more restricted to established sufferers. These sufferers who obtained distant monitoring companies throughout the PHE however who didn’t endure an preliminary new affected person examination will likely be deemed “established sufferers” beneath CMS’ current rule clarification.
In sum, Medicare sufferers who obtained preliminary RPM companies throughout the PHE will likely be thought of established sufferers (i.e., sufferers who started receiving RPM companies throughout the PHE will likely be “grandfathered” in). These sufferers who obtain preliminary RPM companies after Might 11, 2023 (the tip 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 (not 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 tip 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 therapy 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 attainable that failing to finish this preliminary interplay and create a therapy plan may expose RTM practitioners to post-payment audits based mostly on Medicare’s “affordable and crucial” normal. CMS stated it should make clear this coverage in future rulemaking.
Practitioners Should Acquire at Least 16 Days of Information Per 30-Day Interval
Within the 2024 Last Rule, CMS clarified which distant monitoring codes require not 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 all RPM and RTM codes required not less than 16 days of information assortment – each the set-up and gadget monitoring codes (CPT codes 99453, 98976, 99454, 98977, and 98978) and the therapy administration codes (CPT codes 98976, 98977, 98978, 98980, and 98981). Nevertheless, there was ambiguity as as to whether or not the 16-day requirement utilized to the 4 therapy administration codes. We highlighted this ambiguity in our earlier weblog publish and inspired stakeholders to submit feedback advocating for better flexibility on the 16-day requirement.
Within the 2024 Last Rule, CMS wrote:
We be aware 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 want 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 therapy 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 therapy administration codes (CPT codes 99457, 99458, 98980, and 98981).
Solely One Practitioner Can Invoice Medicare for RPM/RTM Providers
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 not less than 16 days of information has been collected on not less than one medical gadget. “Even when a number of medical gadgets are supplied to a affected person,” CMS defined, “the companies related to all of the medical gadgets could be billed by just one practitioner, solely as soon as per affected person, per 30-day interval and solely when not less than 16 days of information have been collected.” Furthermore, remotely-monitored month-to-month companies must be billed solely when affordable and crucial, in step with prior CMS steerage.
When reiterating that just one practitioner can invoice these codes, CMS didn’t expressly checklist the 2 codes for RPM therapy administration companies (CPT codes 99457 and 99458), though CMS did checklist the 2 codes for RTM therapy 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 attainable that such billing may expose RPM practitioners to assert denials or post-payment audits based mostly on Medicare’s “affordable and crucial” normal.
Use of RPM/RTM with Different Providers
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 shouldn’t be 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 suitable mixture of care administration companies for sufferers, whereas nonetheless guarding in opposition to fraud, waste, and abuse.
This restriction shouldn’t be restricted to Medicare. The 2023 CPT Codebook Steerage explains that CPT code 98980/98981 (RTM therapy administration) can’t be reported together with CPT codes 99457/99458 (RPM therapy administration).
Billing RPM or RTM Throughout International 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 fee overlaying 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 international interval. It’s because the worldwide billing fee obtained by the practitioner covers these post-surgical follow-up companies throughout the interval. This coverage was clarified within the 2024 Last Rule.
Nevertheless, the coverage that prohibits RPM or RTM companies being furnished throughout the international interval solely applies to billing practitioners who’re receiving the worldwide service fee. Practitioners, equivalent to therapists, who usually are not receiving a worldwide service fee 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 throughout the international interval is permitted if the practitioner shouldn’t be receiving international service fee 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 beneath international 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 could 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 international 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 international process – that means that the distant monitoring companies handle an underlying situation that isn’t linked to the international process or service.
FQHCs and RHCs Might Obtain Separate Reimbursement for RPM and RTM Providers
Traditionally, Federally Certified Well being Facilities (FQHCs) and Rural Well being Clinics (RHCs) weren’t licensed to individually invoice for RPM and RTM companies, and fee was made by an all-inclusive price somewhat than separate reimbursement. Starting January 1, 2024, FQHCs and RHCs could now individually invoice Medicare for RPM and RTM. They achieve this utilizing the overall care administration code (HCPCS code G0511) on an FQHC or RHC declare kind. The RPM/RTM companies should be medically affordable and crucial, meet all of the coding necessities, and can’t be duplicative of companies already paid for beneath the overall care administration code for an episode of care in a given calendar month.
RHCs and FQHCs could invoice HCPCS code G0511 a number of instances in a calendar month, in keeping with CMS’ commentary, supplied all necessities are met and useful resource prices usually are not counted greater than as soon as. CMS will publish the ultimate 2024 fee price for the overall care administration HCPCS code G0511 on the RHC and FQHC heart web sites (which could 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. Nevertheless, Medicare rules 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 beneath 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) beneath 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 alteration is completed by 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 alteration: Medicare will proceed to require PTPPs and OTPPs to straight supervise their employed PTs and OTs if the PT or OT being supervised shouldn’t be individually enrolled in Medicare.
RPM is Not Included within the Definition of Main Care Providers for MSSP
Within the Proposed Rule, CMS thought of including RPM CPT codes 99457 and 99458 to the definition of main care companies used for functions of beneficiary task within the Medicare Shared Financial savings Program (MSSP). Within the Last Rule, nonetheless, CMS selected to not add these codes.
Primarily based on its commentary, CMS’ concern is that whereas RPM codes could possibly be billed by main care suppliers to assist the general administration of a affected person’s care, the codes can be billed by specialists. As a result of just one treating practitioner can invoice RPM for a given affected person, if a specialist payments these codes to assist administration of a selected situation, the affected person’s main care supplier wouldn’t be capable of additionally invoice RPM therapy administration companies for the affected person. Consequently, together with the RPM codes within the definition of main care companies for functions of task may inappropriately have an effect on the dedication of the place a beneficiary obtained a plurality of their main care companies beneath MSSP guidelines.
Conclusion
The 2024 Last Rule displays a continued maturation of RPM and RTM Medicare billing steerage. Nevertheless, there continues to be some lack of readability within the operation of RPM and RTM codes, a few of which has been created by the iterative rulemaking course of itself. Stakeholders ought to think about collaborating in future rulemaking in better numbers to extra shortly resolve among the areas of uncertainty to permit these companies to be higher used to assist elevated high quality and innovation in digital well being fashions out there to sufferers.
Need to Be taught Extra?
For extra info on telemedicine, telehealth, digital care, distant affected person monitoring, digital well being, and different well being improvements, together with the workforce, publications, and consultant expertise, go to Foley’s Telemedicine & Digital Well being Business Group.
