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In September, we shared that the Centers for Medicare and Medicaid Services (CMS) had proposed additional new CPT® codes for Remote Therapeutic Monitoring (RTM). These RTM codes had the potential to expand the coverage of remote monitoring in several important ways, including:

  • Monitoring for non-physiological data
  • Inclusion of self-reported data
  • Inclusion of additional practitioners eligible for reimbursement

CMS released its final ruling on November 2, 2021 and our legal experts at Nixon Gwilt Law have evaluated the implications for healthcare organizations. While the new codes will enable practices to expand the conditions eligible for remote monitoring and the practitioners able to deliver those services, outstanding questions remain.

While the final RTM codes do not fully align with the services and structure of RPM, there are parallels as demonstrated in the chart below. The RPM codes are evaluation and management (E/M) services, whereas the RTM codes are general medicine codes, which allows a broader range of providers to order and bill for RTM. The examples that CMS cites for data that may be monitored through RTM include, “respiratory system status, musculoskeletal system status, therapy adherence, therapy response.”

  RPM RTM
Initial set-up and patient education on use of the equipment CPT® code 99453 CPT® code 98975
Device(s) supply with daily recording(s) or programmed alert transmission, each 30 days CPT® code 99454

CPT® code 98976: Supply of Device for Monitoring Respiratory System

CPT® code 98977: Supply of Device for Monitoring Musculoskeletal System

Monitoring/Treatment Management Services, first 20 minutes CPT® code 99457:
clinical staff, QHCP, or physician time
CPT® code 98980:
physician/other qualified health care professional (QHCP) time or clinical staff under direct supervision of providers eligible for incident-to billing
Monitoring/Treatment Management Services, each additional 20 minutes CPT® code 99458:
clinical staff, QHCP, or MD
CPT® code 98981:
physician/other qualified health care professional time or clinical staff under direct supervision of providers eligible for incident-to billing

 

So, what does this all mean in terms of how practices can expand their remote monitoring programs?

  • Conditions: The CMS ruling discusses “health conditions, including musculoskeletal system status, respiratory system status,” so while it seems like health conditions can be interpreted broadly, the two RTM device supply codes focus specifically on devices that monitor a patient’s Respiratory System or Musculoskeletal System. According to Nixon Gwilt, this could limit the conditions that are eligible for reimbursement unless CMS issues a system-agnostic device code.

  • Types of Data: RPM only allows physiologic data, such as blood pressure, blood sugar levels, or weight. RTM is more expansive and allows “non-physiologic” and “self-reported” data. This includes “therapy adherence” and “therapy response” data. As an example, an asthma patient could use a device that tracks usage of an inhaler as well as environmental factors, such as pollen counts. While RPM requires that a device automatically transmit data, RTM data can be self-reported in an app or online platform that is shared with the provider (subject to the device requirements below).

  • Devices: Like RPM, devices used for RTM must meet the FDA’s definition of a medical device. While the RTM treatment codes (CPT codes 98980 and 98981) do not specifically limit conditions to musculoskeletal or respiratory conditions, the CMS device codes (codes 98975-77) do specifically refer to these two categories. According to Nixon Gwilt, this may limit reimbursement opportunities.

  • Ordering Providers: Unlike RPM, RTM can be ordered by Qualified Health Care Practitioners (“QHCPs”) who cannot independently order and bill evaluation and management (E/M) services, including physical therapists, occupational therapists, dietitians, clinical psychologists, and other QHCPs who are eligible to bill the general medicine codes. Physician or non-physician practitioner supervision is not needed.

  • Monitoring Staff: The CMS RPM codes explicitly state that clinical staff, including nurses and in many cases medical assistants, can count time towards the 20 minutes of monitoring and treatment requirement. However, the CMS language for RTM specifically says “physician/other qualified healthcare professional time.” Providers who are eligible to leverage clinical staff on an incident-to basis will still be able to do so, but only under direct supervision.

  • Reimbursement Rates: RTM will be reimbursed at the same rate as RPM.

While RTM opens many possibilities, “therapy adherence” is mentioned repeatedly in the 2022 Medicare Physician Fee Schedule Final Rule. With 125,000 deaths a year driven by medication nonadherence in the US, this could be one of the most promising opportunities to arise from the RTM codes. With adherence for chronic condition medications estimated to be only 50 percent, there is significant room for improvement. We’ve already seen how RPM can increase patient engagement and accountability through daily interactions with a care team member. Leveraging the built-in engagement tools of an RPM program with a smart-pill cap, such as Pillsy, has the potential to dramatically reduce the adverse outcomes of nonadherence.

CMS’ adoption of the new RTM codes is a clear indication that they believe remote monitoring is effective in driving positive clinical outcomes and reducing costs. The RTM codes open up multiple ways to increase the number of patients that can benefit from remote monitoring. However, in line with Nixon Gwilt’s guidance, we hope that CMS will further clarify and amend the RTM codes in the future. Allowing devices beyond respiratory and musculoskeletal and the use of clinical staff to conduct the monitoring under general supervision will enable more practical implementation.

 

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