CMS Clarifies 2021 PFS Reimbursements for Remote Patient Monitoring

The Centers for Medicare & Medicaid Services has made corrections to the 2021 Physician Fee Schedule, opening the door to improved reimbursement for remote patient monitoring.

In a January 19 update posted in the Federal Register, CMS amended a requirement for RPM coverage that had drawn criticism from telehealth advocates following the December 2020 release of the final rule. The change clarifies how healthcare providers will be paid for using RPM platforms to gather physiologic data from patients at home.

In the final rule, to qualify for reimbursement under CPT codes 99457 and 99458, CMS mandated at least 20 minutes of interactive communication time between provider and patient over a calendar month, but that interactive communication couldn’t be part of the 20 minutes of RPM care. The agency has now clarified that “interactive communication” can include both in-person and connected health channels.

Both the Alliance for Connected Care – which drew attention to this week’s corrections – and the healthcare team at Foley & Lardner criticized the initial guidelines when they were released in a preliminary draft last August.

“This is the first time CMS provided published guidance on the interactive communication requirement in the context of RPM and is not how most of the industry has, to date, viewed the requirement, is not consistent with clinical need, nor is it consistent with the way the code is valued,” Thomas (TJ) Ferrante, senior counsel at the Foley & Lardner law firm and a member of its Telemedicine & Digital Health Industry Team, said in an August 6 blog. “We anticipate (and encourage) significant industry stakeholder push back on this in the public comments requesting that 99457 and 99458 can be billed for the time spent during the calendar month both reviewing the data and communicating with the patient about the data, short of an actual patient visit.”

“A more reasonable reading of the code descriptor and intent is that the interactive communication with the patient is part of the 20 minute minimum, but the practitioner can also include time spent reviewing and analyzing the patient’s RPM data and determining how to change the care management accordingly,” Ferrante and his colleagues wrote.

When the final rule came out in December, the Foley & Lardner team noted that the condition was amended in a fact sheet accompanying the ruling, but wasn’t contained in the ruling itself. This week’s correction makes that change official.

“We agree with commenters that our description of the required 20 minutes of time associated with CPT codes 99457 and 99458 should include care management services, as well as synchronous, real-time interactions,” CMS wrote. “That is, we agree that ‘interactive communication’ as we defined it in the CY 2021 PFS proposed rule contributes to the total time, but is not the only activity that should be included in the total time.”

More importantly, it gives providers more leeway in developing protocols for collecting data and communicating with patients via an RPM platform.

In addition, CMS added more context to a requirement that bases RPM reimbursement on a minimum of 16 days of data collected over a 30-day period, and said RPM services associated with CPOT codes 99453 and 99454 could be billed once per provider per patient per 30-day period.

When the final rule was issued in December, Carrie Nixon, co-founder and managing partner of the Nixon Gwilt law firm, took exception to the requirement that 16 days of data be collected over a 30-day period.

“Numerous stakeholders responded with clinical examples of such conditions that could readily be managed with fewer data transmissions, and even some instances in which requiring 16 separate transmission can be damaging to patients – for example, transmission of a patient’s weight in managing obesity,” she said. “Despite these specific examples, CMS stated in the Final 2021 MPFS that 'although we received general support for a reduction in the number of days of data collection required to bill for CPT codes 99453 and 99454, we did not receive specific clinical examples … we are not extending the interim policy to permit billing for CPT codes 99453 and 99454 for fewer than 16 days in a 30-day period.' Notably, the Final 2021 MPFS does not appear to prohibit billing CPT codes 99457 and 99458 when 20 minutes of care management services time has accrued during a calendar month, regardless of whether or not 16 days of transmissions have occurred during that time.”

Foley & Lardner also had problems with the one-practitioner rule.

“CMS comments about RPM being billed by only one practitioner is new, and when read in context of the Final Rule, it remains unclear if CMS means a practitioner cannot bill multiple RPM services for the same patient in the same month, or if it means CMS will pay only one RPM claim per beneficiary per month,” the Foley & Lardner team, led by Nate Lacktman, partner and chair of the firm’s national Telemedicine & Digital Health Industry Team, wrote in a December blog. “If the former, a patient could enroll in different RPM programs with different specialists during the same time period (e.g., a cardiologist for the patient’s heart needs and an endocrinologist for the patient’s diabetes) and each specialist could bill Medicare for their respective RPM services. If the latter, a patient could enroll in only one practitioner’s RPM program, which is how CCM services are currently structured. CMS’ billing guidance for CCM is expressly clear about this restriction, but the RPM guidance does not use a similarly explicit statement, so there remains definite ambiguity.”

Those arguments didn’t sway CMS to change its mind.

“As we stated in the proposed rule, we believe these two codes should be reported for a patient only once during a 30-day period and only when reasonable and necessary,” CMS explained in this week’s amendment. “In response to public commenters, we are clarifying that only one practitioner can bill CPT codes 99453 and 99454 during a 30-day period and only when at least 16 days of data have been collected on at least one medical device as defined in section 201(h) of the FFDCA. CPT language suggests that even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.”

“We also note that when a more specific code is available to describe a service, CPT indicates that the more specific code should be billed,” the agency continued. “We believe that there are additional, more specific codes available for billing that allow remote monitoring (for example, CPT code 95250 for continuous glucose monitoring and CPT codes 99473 and 99474 for self-measured blood pressure monitoring).”

“In summary,” it said, “we are clarifying that CPT codes 99453 and 99454 should be reported only once during a 30-day period; that even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed by only one practitioner, only once per patient, per 30-day period, and only when at least 16 days of data have been collected; and that the services must be reasonable and necessary.”