On November 2, 2023, the Facilities for Medicare & Medicaid Providers (CMS) finalized new insurance policies associated to distant physiologic monitoring (RPM) and distant therapeutic monitoring (RTM) providers reimbursed beneath the Medicare program.
The steerage printed within the 2024 Doctor Charge Schedule last rule (2024 Ultimate Rule) addresses billing eventualities 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 providers. CMS rejected among 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 concerning the 2024 Ultimate Rule.
RPM and RTM Clarifications
RPM Can Solely be Furnished to an “Established Affected person”
In prior rulemaking, RPM providers have been restricted to “established sufferers.” Traditionally, to be able to grow to be 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. In the course of the Public Well being Emergency (PHE), CMS waived the established affected person requirement. When the PHE expired in Could 2023, RPM providers had been as soon as once more restricted to established sufferers. These sufferers who obtained distant monitoring providers throughout the PHE however who didn’t bear an preliminary new affected person examination will likely be deemed “established sufferers” beneath CMS’ current rule clarification.
In sum, Medicare sufferers who obtained preliminary RPM providers throughout the PHE will likely be thought-about established sufferers (i.e., sufferers who started receiving RPM providers throughout the PHE will likely be “grandfathered” in). These sufferers who obtain preliminary RPM providers after Could 11, 2023 (the tip of the PHE) might want to grow to be a longtime affected person earlier than enrolling in a Medicare RPM providers program.
RTM Does Not Comprise an “Established Affected person” Requirement
Whereas RPM providers require a longtime affected person relationship previous to billing RPM codes, RTM providers haven’t 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, providers require a longtime affected person relationship after the tip of the PHE.” Regardless of the dearth of an categorical requirement, CMS expressed its perception that RTM providers could be furnished to a affected person solely after a remedy plan has been established (and presumably after the billing practitioner performed an preliminary interplay analysis with the affected person).
Beneath present RTM guidelines, the failure to conduct an preliminary affected person analysis and create an “established affected person” relationship will not be a per se deviation of RTM billing necessities, however it stays potential that failing to finish this preliminary interplay and create a remedy plan may expose RTM practitioners to post-payment audits primarily based on Medicare’s “cheap and crucial” commonplace. CMS mentioned it should make clear this coverage in future rulemaking.
Practitioners Should Accumulate 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 information assortment in a 30-day interval, and which codes haven’t any such requirement. Prior CMS commentary indicated the RPM and RTM set-up and system codes (CPT codes 99453, 98976, 99454, 98977, and 98978) required at the least 16 days of information assortment. Nevertheless, there was ambiguity as as to whether or not the 16-day requirement utilized to the 4 remedy administration codes (CPT codes 99457, 99458, 98980, and 98981). 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 providers and had made a common assertion concerning the applicability of the 16-day knowledge assortment requirement. We want 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 information assortment in a 30-day interval.
This represents the primary time CMS expressly acknowledged in printed 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 Providers
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 information has been collected on at the least one medical system. “Even when a number of medical gadgets are offered to a affected person,” CMS defined, “the providers related to all of the medical gadgets will 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 information have been collected.” Furthermore, remotely-monitored month-to-month providers needs to be billed solely when cheap and crucial, according to 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 providers (CPT codes 99457 and 99458), though CMS did listing the 2 codes for RTM remedy administration providers. In future rulemaking, stakeholders ought to take into account 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 will 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 potential that such billing may expose RPM practitioners to say denials or post-payment audits primarily based on Medicare’s “cheap and crucial” commonplace.
Use of RPM/RTM with Different Providers
Practitioners are permitted to invoice Medicare for RPM or RTM (however not each) concurrently with the next care administration providers for a similar affected person as long as the effort and time isn’t counted twice: Persistent Care Administration (CCM), Transitional Care Administration (TCM), Behavioral Well being Integration (BHI), Principal Care Administration (PCM), and Persistent Ache Administration (CPM). By permitting this concurrent billing, CMS intends to afford practitioners most flexibility when deciding on the precise mixture of care administration providers for sufferers, whereas nonetheless guarding in opposition to fraud, waste, and abuse.
This restriction isn’t restricted to Medicare. The 2023 CPT Codebook Steerage explains that CPT code 98980/98981 (RTM remedy administration) can’t be reported along side CPT codes 99457/99458 (RPM remedy administration).
Billing RPM or RTM Throughout International Surgical procedure Durations
When a billing practitioner furnishes a process or surgical procedure topic to a worldwide billing interval (the place the practitioner receives a lump cost overlaying the post-surgical follow-up providers inside the worldwide interval), that practitioner can’t invoice Medicare for RPM or RTM providers offered to the affected person throughout that world interval. It’s because the worldwide billing cost obtained by the practitioner covers these post-surgical follow-up providers throughout the interval. This coverage was clarified within the 2024 Ultimate Rule.
Nevertheless, the coverage that prohibits RPM or RTM providers being furnished throughout the world interval solely applies to billing practitioners who’re receiving the worldwide service cost. Practitioners, corresponding to therapists, who usually are not receiving a worldwide service cost as a result of they didn’t furnish the worldwide process, are permitted to furnish RPM or RTM providers throughout a worldwide interval. Offering RTM or RPM providers throughout the world interval is permitted if the practitioner isn’t receiving world service cost as a result of they didn’t furnish the worldwide process. This implies, for instance, a physician can carry out surgical procedure on a affected person beneath 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 providers throughout a worldwide interval, a practitioner might furnish RPM or RTM providers (however not each) to the affected person, and Medicare pays the practitioner individually for the RPM or RTM, as long as the distant monitoring providers are unrelated to the analysis 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 providers 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 Providers
Traditionally, Federally Certified Well being Facilities (FQHCs) and Rural Well being Clinics (RHCs) weren’t licensed to individually invoice for RPM and RTM providers, and cost was made by means of an all-inclusive price slightly than separate reimbursement. Starting January 1, 2024, FQHCs and RHCs might now individually invoice Medicare for RPM and RTM. They achieve this utilizing the overall care administration code (HCPCS code G0511) on an FQHC or RHC declare type. The RPM/RTM providers have to be medically cheap and crucial, meet all of the coding necessities, and can’t be duplicative of providers already paid for beneath the overall 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, based on CMS’ commentary, offered all necessities are met and useful resource prices usually are not counted greater than as soon as. CMS will submit the ultimate 2024 cost price for the overall care administration HCPCS code G0511 on the RHC and FQHC middle web sites (which will be accessed right here and right here).
Bodily Therapists and Occupational Therapists can Invoice RTM for Assistants Beneath Common Supervision
Bodily therapists (PTs) and occupational therapists (OTs) can present and invoice Medicare for RTM providers. Nevertheless, Medicare laws for PTs and OTs in personal apply (PTPPs and OTPPs) required all bodily and occupational remedy providers in that setting to be carried out by, or beneath the direct supervision of, the PT or OT. Requiring direct supervision ranges renders it troublesome for PTPPs and OTPPs to invoice for RTM providers carried out by assistants (PTAs and OTAs) beneath their supervision.
Starting January 1, 2024, Medicare will solely require common supervision for PTPPs and OTPPs to invoice for RTM providers furnished by their PTAs and OTAs. This variation is achieved by means 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 instantly supervise their employed PTs and OTs if the PT or OT being supervised isn’t individually enrolled in Medicare.
RPM is Not Included within the Definition of Major Care Providers for MSSP
Within the Proposed Rule, CMS thought-about including RPM CPT codes 99457 and 99458 to the definition of main care providers used for functions of beneficiary project within the Medicare Shared Financial savings Program (MSSP). Within the Ultimate Rule, nonetheless, CMS selected to not add these codes.
Based mostly on its commentary, CMS’ concern is that whereas RPM codes may very well be billed by main care suppliers to help the general administration of a affected person’s care, the codes can 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 providers for the affected person. Consequently, together with the RPM codes within the definition of main care providers for functions of project may inappropriately have an effect on the dedication of the place a beneficiary obtained a plurality of their main care providers beneath MSSP guidelines.
The 2024 Ultimate Rule displays a continued maturation of RPM and RTM Medicare billing steerage. Nevertheless, 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 take into account collaborating in future rulemaking in higher numbers to extra shortly resolve among the areas of uncertainty to permit these providers to be higher used to help elevated high quality and innovation in digital well being fashions out there to sufferers.
Need to Study Extra?
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