Introduction on Final Rule
On November 23, 2023, the Centers for Medicare & Medicaid Services (CMS) published the final rule for payment policies under the Physician Fee Schedule for calendar year 2024 (Final Rule). This Final Rule contained, in relevant part, important clarifications on previous CMS guidance, as well as new policies regarding billing for remote monitoring services. Providers offering remote monitoring services in calendar year 2024, or those who are interested in providing remote monitoring services, should familiarize themselves with current CMS policies and guidance on this topic.
Background
As noted in the Final Rule, CMS has established two code families for remote monitoring services: remote physiologic monitoring (RPM) and remote therapy monitoring (RTM). RPM services were approved by CMS for Medicare coverage in 2019 and include services intended to gather physiologic data on patients, such as weight, blood pressure, respiratory flow rate, and others. CMS approved RTM services for Medicare coverage effective in the calendar year 2022 and include services intended to gather data on a patient’s response to treatments by monitoring signs of therapeutic response such as musculoskeletal and respiratory system activity.
During the COVID-19 Public Health Emergency (PHE), CMS implemented temporary flexibilities and adjustments to policies to facilitate the use of remote monitoring services. However, as discussed in the Final Rule, certain of those flexibilities and policies expired on May 11, 2023, the last day of the PHE declaration. Thus, CMS felt the need to publish new, updated guidance and clarifications on RPM and RTM services.
Final Rule Clarifications and New Policies
New vs. Established Patient Requirements
RPM services may only be furnished to an established patient of a provider. An “established patient” is typically a patient who has undergone evaluation by a billing provider who collects information on the patient and establishes a treatment plan which may include RPM services. During the PHE, the “established patient” requirement was waived. However, now that the PHE is expired, RPM services are once again restricted to established patients, except for any patients who received RPM services during the PHE. These patients will be grandfathered in as an “established patient” and may continue to receive RPM services. Importantly, this clarification and criteria does not apply to RTM services. As noted in the Final Rule, “RPM, not RTM, services require an established patient relationship after the end of the PHE.” However, CMS does go on to state that it expects RTM services would be furnished to a patient after a treatment plan has been established. Thus, while not a per se violation of CMS’s rules, providers should be wary of providing RTM services to unestablished patients.
Data Collection Requirements
CMS clarified that practitioners must collect at least 16 days of data per 30-day reporting period for RPM and RTM CPT codes. Specifically, 16 days of data collection in a 30-day period are required for RPM and RTM CPT codes 99453, 98976, 99454, 98977 and 98978. This a change from the policy during the PHE which allowed for billing when less than 16 days of data were collected under certain RPM and RTM CPT codes. Significantly, CMS does clarify in the Final Rule that the 16-day collection requirement does not apply to treatment management CPT codes 99457, 99458, 98980 and 98981, as these codes account for time spent in a calendar month.
30-Day Reporting Period Limitations
CMS clarifies that for either RPM or RTM services, only one practitioner can bill CPT codes 99543, 99454 (RPM), or 98976, 98977, 98980 and 98981 (RTM) during a 30-day period, and only when at least 16 days of data have been collected on at least one medical device. Further, CMS notes 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.” In all cases, remotely monitored monthly services should only be billed when reasonable and necessary.
Use of RPM, RTM in Conjunction With Other Services
Providers are allowed to bill RPM or RTM services, but not both, concurrently with the following care management services: Chronic Care Management, Transitional Care Management, Behavioral Health Integration, Principal Care Management and Chronic Pain Management. However, it is important to note that CMS clarifies that time or effort must not be counted twice when billing for RPM or RTM concurrently with the above care management services. The intent, as CMS explains, is “to allow the maximum flexibility for a given practitioner to select the appropriate mix of care management services, without creating significant issues of possible fraud, waste, and abuse associated with overbilling of these services.” CMS also clarifies that RPM and RTM services may not be billed together for concurrent RPM or RTM services. This is true even if multiple devices are used, consistent with the Final Rule clarifications noted in the discussion of the 30-Day Reporting Period Limitations.
Clarification on Billing RPM or RTM Services During a Global Service Period
RPM or RTM services (but not both) may be billed for, and providers may receive a separate payment for such services, during a global service period, “so long as the remote monitoring services are unrelated to the diagnosis for which the global procedure is performed, and as long as the purpose of the remote monitoring addresses an episode of care that is separate and distinct from the episode of care for the global procedure — meaning that the remote monitoring services address an underlying condition that is not linked to the global procedure or service.” Thus, a provider who is providing RPM or RTM services to a patient, and subsequently provides a global procedure or service, may continue to bill for and receive a separate payment for RPM or RTM services if those services are not linked to the underlying condition which prompted the need for the global procedure or service.
Related to the above, CMS commented that the restriction on billing for RPM or RTM services during a global service period only applies to the billing provider who is receiving the global payment. CMS, as an example, notes that while a patient may be subject to a global service period, a practitioner, such as a therapist who is not receiving the payment for a global procedure because they did not provide it, would be permitted to furnish and bill for RPM or RTM services during the global period.
Overall, this Final Rule reflects that while the PHE-flexibilities related to RPM and RTM services may have ended, CMS continues to allow for the use of RPM and RTM services. We anticipate that iterative rulemaking by CMS in the future will continue to create new rules and guidance for RPM and RTM services.
