What we know so far about remote therapeutic monitoring, remote patient monitoring and preventive services.
In early November, the Centers for Medicare & Medicaid Services issued its 2023 Physician Fee Schedule (PFS) final rule. I recently presented a webinar on the subject, focusing on developments concerning care management and the remote/virtual delivery of these services. There were some significant changes, so I thought it would be helpful to provide a summary of some of the key things to know about how the 2023 final rule impacts remote monitoring and related topics — with the caveat that we're awaiting additional information on some topics and expect further clarity on others in future rules.
Of all the care management services, remote therapeutic monitoring (RTM) received the most attention in the final rule. Before summarizing the changes to RTM included in the rule, I thought it would be helpful to provide an overview of these services, which are only a few years old and have changed quite a bit since they were revealed.
The American Medical Association defines RTM services as those that "represent the review and monitoring of data related to signs, symptoms, and functions of a therapeutic response." These data may represent objective device-generated data or subjective inputs reported by a patient captured via "software as a medical device" (SaMD). RTM is billable by physicians, nonphysician practitioners, and other qualified providers (e.g., physical therapists, dietitians, clinical psychologists).
Remote therapeutic monitoring and remote patient monitoring (RPM) are sometimes confused. RPM involves collecting physiological/vital data from a connected medical device, whereas RTM involves collecting non-physiological (i.e., "therapeutic") data from a connected medical device. RPM is device-neutral, whereas RTM is currently limited to respiratory monitoring, musculoskeletal monitoring, and cognitive behavioral monitoring, the latter of which is new for 2023 and discussed further below.
The 2023 PFS proposed rule would have replaced existing RTM CPT codes 98980 (monitoring/treatment management services, first 20 minutes) and 98981 (monitoring/treatment management services, each additional 20 minutes) with four new HCPCS G-codes — two that would be used by physicians and or non-physician practitioners and two that would be used by non-physician qualified healthcare professionals. This led to confusion, so CMS elected not to finalize the codes. For 2023, all eligible providers can continue to bill 98980 and 98981.
The full list of RTM CPT codes for 2023 is as follows:
I want to go back to why CMS proposed replacing the RTM CPT codes in the first place. The agency wanted to get around the established prohibition of general supervision for non-evaluation and management (E/M) services codes. Despite CMS deciding to keep using the original CPT codes, the agency declared in final rule that, "Any RTM service may be furnished under our general supervision requirements."
This is a big win for RTM services as easing supervision requirements should encourage increased provision of the services. Yet, some questions remain concerning who this declaration applies to as there are existing restrictions on incident-to billing for some provider types that can bill for RTM. We hope to receive clarification on this point soon.
An important note about the new RTM device supply code for cognitive behavioral therapy monitoring, CPT 989X6: At this time, there's no national reimbursement amount assigned to the code. That's a departure from other care management-style remote monitoring codes. CMS stated that each Medicare administrative contractor (MAC) will develop its own pricing for CPT 989X6 until the agency "learn(s) more about the devices being used to furnish the service."
Despite urging from providers, CMS rejected the creation of a device-neutral RTM code, stating: "...it remains unclear whether generic device codes would undermine or stall progress toward a wider set of specific codes that would provide less ambiguity." I expect a continued push for the creation of such a code that would bring billing RTM devices in line with billing RPM devices, but CMS does not seem too keen on the idea as of yet.
A noteworthy development concerning remote patient monitoring showed up in the 2023 Home Health Prospective Payment System Rate Update final rule. While CMS does not currently reimburse for RPM for home health organizations, it was announced that CMS will start requiring home health organizations to track telehealth and remote monitoring use through non-reimbursable codes that will document the types of telecommunications technology used under home health benefits.
Initially, home health agencies are asked to voluntarily start reporting on Jan. 1, 2023, with the requirement taking affect in July 2023. The codes agencies should use include:
Note: Learn more about these new home health G-codes in this MLN Matters piece.
In 2021, CMS made permanent the rule requiring documentation showing the provision of remote patient monitoring or other services furnished via telecommunications system to be included in a patient's care plan. However, CMS noted that a telecommunication service cannot be substituted for a home visit ordered by the care plan or for eligibility or payment.
These developments show the multi-year trend of CMS gathering information and looking into the viability and value of remote monitoring in home health settings and, more generally, outside of physician practices. Home health advocates have long advocated for CMS to begin reimbursing for home health RPM. The 2023 changes seem like another step toward providing such coverage.
The 2023 PFS final rule included a few other important changes concerning preventive services. Two preventive services had their HCPCS code descriptors modified. HCPCS G0442 was changed to "Annual alcohol misuse screening, 5 to 15 minutes" and HCPCS G0444 was changed to "Annual depression screening, 5 to 15 minutes." The codes currently require a minimum of 15 minutes of services. CMS also expanded Medicare coverage for certain colorectal cancer screening tests by reducing the minimum age payment limitation to 45 years.
In my webinar, I spent some time discussing the new service finalized in the 2023 PFS final rule, chronic pain management (CPM). Despite CMS speaking about CPM as if it was a "care management" service, the agency designated chronic pain management as a "telehealth" service. Such a designation means the remote/virtual provision of CPM must follow CMS telemedicine requirements rather than the more relaxed requirements of a care management service. These requirements may stifle access to and the provision of CPM services. The requirements also mean CPM cannot, as presently described, be integrated into a remote care management program.
While the release of CPM is encouraging, the substantial restrictions currently placed on the service would need to be addressed in future rulemaking for chronic pain management to be another in the line of worthwhile remote services. Given the paths taken by other remote monitoring services, we are hoping CMS will adjust this designation in future rulemaking to help increase access to CPM and further increase access to other remote monitoring services for its beneficiaries.
The 2023 PFS final rule brings good news for remote monitoring and preventive care services and builds upon the positive developments seen in the final rules of previous years. It's clear that these services have solidified their place in our healthcare system, and CMS is committed to expanding coverage. Remote therapeutic monitoring is now a viable and worthwhile service for practices to consider adding to an existing care management program, home health looks to be on a path to reimbursement for remote monitoring services, and preventive care continues to receive revisions that make it easier to deliver and bill for these services.
Daniel Tashnek, JD, is the co-founder and CEO of Prevounce Health, a healthcare software company that simplifies the provision of clinical preventive services, chronic care management, and remote patient management. Prevounce also provides a connected health ecosystem and connected devices to health systems, insurers, and employer wellness programs under its "Pylo" brand. Prior to founding Prevounce, Daniel was a practicing healthcare attorney specializing in regulatory compliance, reimbursement, scope of practice, and patient care issues.