CMS Expands Remote Patient Monitoring Coverage in Proposed 2022 PFS

Remote patient monitoring may be catching on with health systems across the country, but its path to Medicare reimbursement is still a work in progress.

The Centers for Medicare & Medicaid Services has included a new category of CPT codes in its proposed 2022 Physician Fee Schedule to address what it calls “remote therapeutic monitoring.” And while it adds coverage for some new services alongside the remote physiological monitoring codes introduced in 2019, connected health advocates say new codes are creating a lot of questions that will need to be answered when the final draft comes out.

Building off of guidelines set by the American Medical Association’s Digital Medicine Payment Advisory Group over the past year, CMS has proposed the following CPT codes for RTM coverage:

• CPT code 989X1: 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;
• CPT code 989X2: 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 to monitor respiratory system, each 30 days;
• CPT code 989X3: 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 to monitor musculoskeletal system, each 30 days;
• CPT code 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
• CPT code 989X5: Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month, each additional 20 minutes (List separately in addition to code for primary procedure).

Together with the RPM codes introduced by CMS earlier, the RTM codes give healthcare providers more opportunities for reimbursement in remote patient monitoring programs, both in data collected and in who’s able to collect and use that data. But experts who’ve analyzed the proposed codes say they are far from complete.

“The CMS proposed rule advances the ability of clinicians to use remote monitoring technologies to improve the patient care experience, but the technical details still need to be ironed out,” notes Nathaniel Lacktman, a partner with the Foley & Lardner law firm and chair of the firm’s Telemedicine & Digital Health Industry Team, and Thomas Ferrante, a partner with Foley & Lardner, in a blog posted last week.

“While this new code set is welcomed by advocates for virtual care, the 2022 Proposed MPFS that discusses RTM may raise just as many questions as it answers,” adds Carrie Nixon, a managing partner of Nixon Gwilt Law, in a separate blog.

The next two months will be crucial, as CMS will be accepting comments on the proposed PFS through 5 p.m. ET on September 13. In years past, the agency has used those comments to amend its original draft when necessary.

For now, among the positives, Nixon says, is that CMS is proposing to reimburse RTM service codes 989X4 and 989X5 at the same rate as it reimburses for RPM services in codes 99457 and 99458.

“This is great news for therapists and other Qualified Health Care Professionals (QHCPs),” she says.

“The recent RTM proposal recognizes the benefit of remote monitoring and continues to foster the use of digital health tools to give clinicians a more comprehensive data set of their patients’ health conditions,” Lacktman and Ferrante say.

They say the new codes expand the palette for RPM coverage to include data on health conditions like musculoskeletal system status, respiratory system status, therapy adherence and therapy response, and the list implies that other conditions can be monitored as well.

“Compared to RPM, the RTM codes offer the promise of broader use cases and applications in patient care,” they add.

“CMS does not specifically define ‘non-physiologic data,’ but notes that RTM should be used to monitor health conditions through data related to, for example, musculoskeletal system status, respiratory system status, ‘therapy (medication) adherence,’ and ‘therapy (medication) response,’” Nixon says in her analysis. “These examples allude to a broad range of data that has long been important to monitoring patients’ health.”

This, in turn, offers opportunities for more care providers to bill for remote patient monitoring services.

“CMS specifically indicates that ‘[s]takeholders have suggested that the new RTM coding was created to allow practitioners who cannot bill RPM codes to furnish and bill for services that look similar to those of RPM,’ and points to documents from the RUC – the committee responsible for valuation of codes – that seem to anticipate nurses and physical therapists as primary billers for these codes,” Nixon says. “This is encouraging news for physical therapists, occupational therapists, speech language pathologists, clinical psychologists, and other practitioners that are not currently eligible to bill for RPM. However, CMS also notes some uncertainty regarding the coding structure, so it will be important for stakeholders to submit comments to ensure this flexibility is finalized.”

Lacktman and Ferrante offer an example of how the new codes can be used. A patient living with asthma is prescribed an inhaler along with an mHealth device that attaches to the inhaler and tracks its use. A care provider can then monitor how often the patient uses the inhaler, how many doses of medicine he/she uses and the environmental conditions, such as pollen count, that affect treatment. The provider can then use that non-physiologic data to track medication adherence and alter the care management plan as needed.

After that, things get murky.

Lacktman and Ferrante note the RTM device supply codes, in contrast, apply to very specific use cases – respiratory and musculoskeletal systems. That omits programs addressing, for example, neurological, vascular, endocrine and digestive systems.

“Limiting reimbursement to these specific device types ignores Software as a Medical Device and other devices that collect important non-physiologic data on pain, mood, adherence, etc.,” Nixon adds.

Nixon, Lacktman and Ferrante also note that in modelling the RTM codes after the RPM codes, they’re designed to be billed as “incident to” services – which can’t be billed by certain providers, like physical therapists.

“This is contrary to what CMS acknowledges as a primary stated intent for the RTM codes, and would seem to indicate that therapists would have to bill RTM ‘incident to’ a physician, nurse practitioner, or physician assistant,” Nixon says. “Further, unlike the codes descriptors for RPM CPT codes 99457 and 99458, nothing in the RTM code descriptors references time spent by ‘clinical staff,’ which typically implicates incident to billing.”

That said, Nixon notes that CMS clearly states that RTM is not a care management service, unlike RPM. So that while RPM codes are classified as E/M codes, RTM are classified as general medicine codes.

Lacktman and Ferrante questioned which providers can bill for RTM services, noting that the codes seem to be designed for nurses and physical therapists, which would make them general medicine codes rather than E/M codes. The two say there are a few inconsistencies in the proposed rule that will need to be ironed out in the final rule to clarify who can bill for these services.

They also note that unlike RPM data, which must be gathered automatically, RTM data can be self-reported by the patient.

“Both RTM and RPM require the use of a medical device,” they note. “However, according to CMS’ commentary, RTM data can be self-reported by the patient, as well as digitally uploaded via the device. In contrast, RPM requires the device to digitally (that is, automatically) record and upload patient physiologic data (i.e., data cannot be patient self-recorded, self-reported, or entered manually into the device). It is unclear what AMA or RUC materials CMS relied upon when determining the RTM codes allow a patient to self-report the data, particularly as that interpretation does not mirror RPM device requirements.”

Nixon calls this an “important distinction from the RPM codes,” in that it opens the door to “software as a medical device (SaMD)” services like mHealth apps and web-based platforms. CMS is, in fact, asking for comments on what kinds of technology should be covered.

Finally, Nixon pointed out that the proposed 2022 PFS doesn’t make any changes to the current RPM codes, which had drawn some criticism last year.

“This is a disappointment to many who had hoped CMS would remedy the limitations imposed by the 16 days’ transmission requirement set forth in the final 2021 MPFS, and should also be raised in comments to CMS on the 2022 Proposed MPFS,” she said.