On July 13th, the Centers for Medicare and Medicaid Services (“CMS”) released its proposed Medicare Physician Fee Schedule for Calendar Year 2022 (the “2022 Proposed MPFS” or the “Proposed Rule”). In doing so, it recognized five new CPT codes for Remote Therapeutic Monitoring (“RTM”) of “non-physiologic” patient data such as “musculoskeletal system status, respiratory system status, therapy (medication) adherence, and therapy (medication) response” as well as pain. 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.
What are Remote Therapeutic Monitoring codes?
The new RTM codes in the Proposed Rule closely resemble the existing Remote Physiologic Monitoring (“RPM”) codes established over the last few years, with a code for set-up and education on the use of RTM equipment, two device codes, and two services codes. Here’s how they are described in the Proposed Rule:
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
CPT code 989X5 – 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; each additional 20 minutes (List separately in addition to code for primary procedure)
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
Remote Therapeutic Monitoring versus Remote Patient Monitoring: What’s the difference?
The proposed RTM codes should be good news for patients, providers, and digital health companies, as the codes attempt to fill some important gaps in current RPM coverage.
RTM covers monitoring of non-physiologic data
For starters, the RTM codes, if finalized, will provide coverage for monitoring of certain data points that are outside the scope of RPM such as pain and medication adherence. While the RPM codes relate to physiologic data, CMS specifies in the Proposed Rule that the RTM codes are intended to cover monitoring of “non-physiologic data.” 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.” These examples allude to a broad range of data that has long been important to monitoring patients’ health.
RTM covers monitoring of self-reported data
Although RTM will still require the use of a “medical device” as defined by the FDA, CMS clarifies in the Proposed Rule that non-physiologic data may include self-reported data. This is an important distinction from the RPM codes, which currently require data to be automatically transmitted by a connected device. Allowing self-reported data, presumably through an app or web-based platform classified as Software as a Medical Device (“SaMD”), is essential to monitoring metrics like pain levels and medication adherence, which may not typically be captured and transmitted through existing hardware devices. CMS is specifically seeking comment on the types and associated costs of devices (including SaMD) that might be used for this type of monitoring in order to appropriately value the device codes.
RTM is intended to be ordered and billed by a broader range of providers, including therapists
In the 2022 Proposed MPFS, 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. 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. More on this below.
Payment parity with RPM
Importantly, CMS is proposing to pay RTM services codes 989X4 and 989X5 at the same rate as the parallel RPM services CPT codes 99457 and 99458. This is great news for therapists and other Qualified Health Care Professionals (“QHCPs”).
Outstanding Questions about Remote Therapeutic Monitoring
The 2022 Proposed MPFS reflects some confusion among CMS policymakers and the American Medical Association’s CPT Editorial Committee and RUC as to what types of practitioners are actually allowed to bill for RTM and how they can go about doing so. This confusion must be clearly resolved in the final 2022 MPFS if RTM is to be adopted as an important component of managing patient care. Issues include:
Is RTM an “incident to” service?
CMS states in the 2022 Proposed MPFS that “[b]y modeling the new RTM codes on the RPM codes, “incident to” services became part of the three direct practice expense-only (PE-only) codes (that is, CPT codes 989X1, 989X2, and 989X3) as well as the two professional work codes (that is, CPT codes 989X4 and 989X5). As a result, the RTM codes as constructed currently cannot be billed by, for example, 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. 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.
Should RTM be considered a care management service?
CMS is explicit that, unlike RPM, RTM is NOT a care management service, stating “RPM services are considered to be E/M services and physical therapists, for example, are practitioners who cannot bill E/M services. The RTM codes, instead, are general medicine codes” and “[t]he treatment management RTM codes (CPT codes 989X4 and 989X5), because they are not E/M codes, cannot be designated as care management services.” CMS also points out that care management services “allow general supervision rather than direct supervision for incident to services.” However, the RTM codes themselves do not seem to implicate incident to billing by clinical staff requiring any supervision.
Can any QHCP practitioner bill for RTM?
CMS repeatedly mentions physical therapists as an example of the type of practitioner who can bill for RTM. While it seems safe to assume that occupational therapists and speech language pathologists could likewise use the RTM codes, can we also presume that other QHCPs such as Clinical Psychologists can use them to monitor important metrics like mood? CMS also mentions use of RTM by nurses, which are typically classified as “clinical staff” whose time is billed incident to a physician or QHCP, thereby circling back to the questions above.
Is reimbursement for RTM devices limited to musculoskeletal and respiratory devices?
Unlike RPM CPT code 99454, which is device-agnostic in providing reimbursement, there are two very specific device codes associated with RTM: CPT Code 989X2 for a device monitoring respiratory system status, and CPT Code 989X3 for a device monitoring musculoskeletal system status. 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.
Public Comment on the proposed 2022 Medicare Physician Fee Schedule
The questions and issues above underscore the importance of providing feedback to CMS’ 2022 Proposed MPFS during the public comment period, which ends at 5:00pm Eastern on September 13, 2021. Notably, the 2022 Proposed MPFS did not include any changes to use of the Remote Patient Monitoring codes. 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.
Please contact us if you would like assistance in preparing and submitting comments around RTM or RPM.