On November 2, 2023, the Facilities for Medicare & Medicaid Companies (CMS) finalized new insurance policies associated to distant physiologic monitoring (RPM) and distant therapeutic monitoring (RTM) companies reimbursed underneath the Medicare program.
The steerage revealed within the 2024 Doctor Charge Schedule closing rule (2024 Ultimate Rule) addresses billing situations and requests for clarifications on the suitable use of those distant monitoring codes. The 2024 Ultimate Rule clarifies CMS’ place on the way it interprets sure necessities for these companies. CMS rejected a number of the proposals contained within the 2024 Proposed Rule and constructed upon earlier RPM and RTM steerage.
Beneath are the important thing takeaways RPM and RTM suppliers should know in regards to the 2024 Ultimate Rule.
RPM and RTM Clarifications
RPM Can Solely be Furnished to an “Established Affected person”
In prior rulemaking, RPM companies have been restricted to “established sufferers.” Traditionally, in an effort to turn into a longtime affected person for Medicare RPM functions, a affected person sometimes would bear a brand new affected person Analysis and Administration (E/M), or comparable service, throughout which the billing practitioner collects related details about the affected person after which establishes a remedy plan. Throughout the Public Well being Emergency (PHE), CMS waived the established affected person requirement. When the PHE expired in Could 2023, RPM companies have been as soon as once more restricted to established sufferers. These sufferers who obtained distant monitoring companies in the course of the PHE however who didn’t bear an preliminary new affected person examination can be deemed “established sufferers” underneath CMS’ current rule clarification.
In sum, Medicare sufferers who obtained preliminary RPM companies in the course of the PHE can be thought of established sufferers (i.e., sufferers who started receiving RPM companies in the course of the PHE can be “grandfathered” in). These sufferers who obtain preliminary RPM companies after Could 11, 2023 (the top of the PHE) might want to turn into a longtime affected person earlier than enrolling in a Medicare RPM companies program.
RTM Does Not Comprise an “Established Affected person” Requirement
Whereas RPM companies require a longtime affected person relationship previous to billing RPM codes, RTM companies don’t have any such categorical requirement (at the least not but). We highlighted this distinction in our prior protection and inspired stakeholders to submit feedback and ask CMS to verify whether or not or not the “established affected person” requirement applies to each RPM and RTM, or simply RPM.
CMS confirmed within the 2024 Ultimate Rule, “RPM, not RTM, companies require a longtime affected person relationship after the top of the PHE.” Regardless of the shortage of an categorical requirement, CMS expressed its perception that RTM companies can be furnished to a affected person solely after a remedy plan has been established (and presumably after the billing practitioner carried out an preliminary interplay analysis with the affected person).
Below present RTM guidelines, the failure to conduct an preliminary affected person analysis and create an “established affected person” relationship might not be a per se deviation of RTM billing necessities, but it surely stays attainable that failing to finish this preliminary interplay and create a remedy plan might expose RTM practitioners to post-payment audits based mostly on Medicare’s “affordable and essential” customary. CMS stated it should make clear this coverage in future rulemaking.
Practitioners Should Gather at Least 16 Days of Information Per 30-Day Interval
Within the 2024 Ultimate Rule, CMS clarified which distant monitoring codes require at the least 16 days of knowledge assortment in a 30-day interval, and which codes don’t have any such requirement. Prior CMS commentary indicated all RPM and RTM codes required at the least 16 days of knowledge assortment – each the set-up and gadget monitoring codes (CPT codes 99453, 98976, 99454, 98977, and 98978) and the remedy administration codes (CPT codes 98976, 98977, 98978, 98980, and 98981). Nonetheless, there was ambiguity as as to whether or not the 16-day requirement utilized to the 4 remedy administration codes. We highlighted this ambiguity in our earlier weblog submit and inspired stakeholders to submit feedback advocating for higher flexibility on the 16-day requirement.
Within the 2024 Ultimate Rule, CMS wrote:
We observe that within the CY 2024 PFS proposed rule, we inadvertently listed all the RTM codes (88 FR 53204) in our dialogue of those companies and had made a common assertion in regards to the applicability of the 16-day knowledge assortment requirement. We wish to provide clarification that the 16-day knowledge assortment requirement doesn’t apply to CPT codes 99457, 99458, 98980, and 98981. These CPT codes are remedy administration codes that account for time spent in a calendar month and don’t require 16 days of knowledge assortment in a 30-day interval.
This represents the primary time CMS expressly said in revealed steerage how the 16-day knowledge assortment requirement doesn’t apply to the RPM and RTM remedy administration codes (CPT codes 99457, 99458, 98980, and 98981).
Solely One Practitioner Can Invoice Medicare for RPM/RTM Companies
In a given 30-day interval, just one practitioner can invoice RPM (CPT codes 99453 and 99454) or RTM (CPT codes 98976, 98977, 98980, and 98981), and solely when at the least 16 days of knowledge has been collected on at the least one medical gadget. “Even when a number of medical units are offered to a affected person,” CMS defined, “the companies related to all of the medical units may be billed by just one practitioner, solely as soon as per affected person, per 30-day interval and solely when at the least 16 days of knowledge have been collected.” Furthermore, remotely-monitored month-to-month companies needs to be billed solely when affordable and essential, in keeping with prior CMS steerage.
When reiterating that just one practitioner can invoice these codes, CMS didn’t expressly listing the 2 codes for RPM remedy administration companies (CPT codes 99457 and 99458), though CMS did listing the 2 codes for RTM remedy administration companies. In future rulemaking, stakeholders ought to think about asking CMS to make clear whether or not or not a number of practitioners can invoice CPT codes 99457 and 99458 for a similar affected person in the identical 30-day interval. Till then, whereas it arguably might not be a per se deviation of RPM billing necessities to have a number of practitioners concurrently invoice Medicare for a similar affected person, it stays attainable that such billing might expose RPM practitioners to say denials or post-payment audits based mostly on Medicare’s “affordable and essential” customary.
Use of RPM/RTM with Different Companies
Practitioners are permitted to invoice Medicare for RPM or RTM (however not each) concurrently with the next care administration companies for a similar affected person as long as the effort and time just isn’t counted twice: Power Care Administration (CCM), Transitional Care Administration (TCM), Behavioral Well being Integration (BHI), Principal Care Administration (PCM), and Power Ache Administration (CPM). By permitting this concurrent billing, CMS intends to afford practitioners most flexibility when deciding on the precise mixture of care administration companies for sufferers, whereas nonetheless guarding towards fraud, waste, and abuse.
This restriction just isn’t restricted to Medicare. The 2023 CPT Codebook Steering explains that CPT code 98980/98981 (RTM remedy administration) can’t be reported together with CPT codes 99457/99458 (RPM remedy administration).
Billing RPM or RTM Throughout World Surgical procedure Intervals
When a billing practitioner furnishes a process or surgical procedure topic to a world billing interval (the place the practitioner receives a lump fee masking the post-surgical follow-up companies inside the worldwide interval), that practitioner can’t invoice Medicare for RPM or RTM companies offered to the affected person throughout that world interval. It is because the worldwide billing fee obtained by the practitioner covers these post-surgical follow-up companies in the course of the interval. This coverage was clarified within the 2024 Ultimate Rule.
Nonetheless, the coverage that prohibits RPM or RTM companies being furnished in the course of the world interval solely applies to billing practitioners who’re receiving the worldwide service fee. Practitioners, corresponding to therapists, who should not receiving a world service fee as a result of they didn’t furnish the worldwide process, are permitted to furnish RPM or RTM companies throughout a world interval. Offering RTM or RPM companies in the course of the world interval is permitted if the practitioner just isn’t receiving world service fee as a result of they didn’t furnish the worldwide process. This implies, for instance, a health care provider can carry out surgical procedure on a affected person underneath world billing, and a bodily therapist can enroll the affected person within the therapist’s RTM program for post-surgery rehab and monitoring.
Correspondingly, CMS defined how, for a affected person who already is receiving RPM or RTM companies throughout a world interval, a practitioner might furnish RPM or RTM companies (however not each) to the affected person, and Medicare pays the practitioner individually for the RPM or RTM, as long as the distant monitoring companies are unrelated to the prognosis for which the world process is carried out, and so long as the aim of the distant monitoring addresses an episode of care that’s separate and distinct from the episode of look after the world process – that means that the distant monitoring companies tackle an underlying situation that’s not linked to the world process or service.
FQHCs and RHCs Could Obtain Separate Reimbursement for RPM and RTM Companies
Traditionally, Federally Certified Well being Facilities (FQHCs) and Rural Well being Clinics (RHCs) weren’t approved to individually invoice for RPM and RTM companies, and fee was made by way of an all-inclusive charge slightly than separate reimbursement. Starting January 1, 2024, FQHCs and RHCs might now individually invoice Medicare for RPM and RTM. They accomplish that utilizing the final care administration code (HCPCS code G0511) on an FQHC or RHC declare kind. The RPM/RTM companies should be medically affordable and essential, meet all of the coding necessities, and can’t be duplicative of companies already paid for underneath the final care administration code for an episode of care in a given calendar month.
RHCs and FQHCs might invoice HCPCS code G0511 a number of instances in a calendar month, in accordance with CMS’ commentary, offered all necessities are met and useful resource prices should not counted greater than as soon as. CMS will submit the ultimate 2024 fee charge for the final care administration HCPCS code G0511 on the RHC and FQHC heart web sites (which may be accessed right here and right here).
Bodily Therapists and Occupational Therapists can Invoice RTM for Assistants Below Basic Supervision
Bodily therapists (PTs) and occupational therapists (OTs) can present and invoice Medicare for RTM companies. Nonetheless, Medicare rules for PTs and OTs in non-public observe (PTPPs and OTPPs) required all bodily and occupational remedy companies in that setting to be carried out by, or underneath the direct supervision of, the PT or OT. Requiring direct supervision ranges renders it tough for PTPPs and OTPPs to invoice for RTM companies carried out by assistants (PTAs and OTAs) underneath their supervision.
Starting January 1, 2024, Medicare will solely require common supervision for PTPPs and OTPPs to invoice for RTM companies furnished by their PTAs and OTAs. This modification is achieved by way of the institution of an RTM particular common supervision provision in 42 C.F.R. § 410.59(a)(3)(ii) and (c)(2) and 42 C.F.R. § 410.60(a)(3)(ii) and (c)(2). One caveat to this transformation: Medicare will proceed to require PTPPs and OTPPs to immediately supervise their employed PTs and OTs if the PT or OT being supervised just isn’t individually enrolled in Medicare.
RPM is Not Included within the Definition of Main Care Companies for MSSP
Within the Proposed Rule, CMS thought of including RPM CPT codes 99457 and 99458 to the definition of main care companies used for functions of beneficiary task within the Medicare Shared Financial savings Program (MSSP). Within the Ultimate Rule, nonetheless, CMS selected to not add these codes.
Primarily based on its commentary, CMS’ concern is that whereas RPM codes might be billed by main care suppliers to help the general administration of a affected person’s care, the codes may also be billed by specialists. As a result of just one treating practitioner can invoice RPM for a given affected person, if a specialist payments these codes to help administration of a particular situation, the affected person’s main care supplier wouldn’t have the ability to additionally invoice RPM remedy administration companies for the affected person. In consequence, together with the RPM codes within the definition of main care companies for functions of task might inappropriately have an effect on the willpower of the place a beneficiary obtained a plurality of their main care companies underneath MSSP guidelines.
The 2024 Ultimate Rule displays a continued maturation of RPM and RTM Medicare billing steerage. Nonetheless, there continues to be some lack of readability within the operation of RPM and RTM codes, a few of which has been created by the iterative rulemaking course of itself. Stakeholders ought to think about collaborating in future rulemaking in higher numbers to extra rapidly resolve a number of the areas of uncertainty to permit these companies to be higher used to help elevated high quality and innovation in digital well being fashions obtainable to sufferers.
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