The 2024 physician fee schedule (PFS) proposed rule has been released by the Centers for Medicare & Medicaid Services (CMS). Within this rule, remote physiologic monitoring (RPM), also known as remote patient monitoring, has garnered significant attention. While customary for a proposed rule, CMS has introduced several suggested modifications to RPM. However, what sets this apart is CMS’s distinctive approach in emphasizing RPM.
To provide you with a quick overview of CMS’s stance on RPM within the proposed rule, here are the main points to consider.
Simultaneous Billing for RPM and RTM
Under the proposed regulations, the Centers for Medicare & Medicaid Services (CMS) have put forth the notion that billing for either remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM) services is acceptable, but not both concurrently. CMS has reiterated the possibility of billing for RTM or RPM services in conjunction with care management services like chronic care management (CCM), transitional care management (TCM), principal care management (PCM), chronic pain management (CPM), and behavioral health integration (BHI) for the same patient. However, this billing must avoid duplicating time or effort in the process. The ability to offer and bill for RPM and CCM simultaneously holds significant benefits for patients, as the synergy of well-executed CCM enhances the efficacy of RPM. Similarly, providers also stand to gain as they can offer enhanced care and receive compensation for their services.
CMS emphasized that its reimbursement strategies concerning the interaction between care management and remote monitoring services are not set in stone. It has solicited input on practitioner experiences with various code sets and services that the agency intends to use for refining and elaborating these policies.
When a patient undergoes both RPM and RTM services that involve multiple monitoring devices, CMS has indicated that its existing regulations would be applicable. According to these rules:
- Billing can be undertaken by a single practitioner.
- Billing can occur only once for each patient within a 30-day period.
- Billing is permissible only after a minimum of 16 days’ worth of data has been collected.
Remote Physiologic Monitoring (RPM) within Surgical Global Periods
CMS has put forward a proposal to provide clearer guidelines on the utilization of remote monitoring within the context of global periods for surgical procedures. According to this proposal, CMS indicated that when beneficiaries are undergoing services within a global period, a provider has the option to offer either remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM) services to the beneficiary. However, it’s important to highlight that both RPM and RTM services cannot be provided simultaneously. In such cases, the practitioner would be eligible for separate payment. Notably, a crucial prerequisite must be observed: the remote monitoring services rendered should be aimed at addressing an underlying condition that is distinct from the global procedure or service being performed
Remote Physiologic Monitoring (RPM) Eligibility for FQHCs and RHCs
At present, federally qualified health centers (FQHCs) and rural health clinics (RHCs) are unable to bill for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) codes. These codes fall under the category of “included” services within the comprehensive rate of these facilities.
In 2019, CMS made a pivotal move by separating chronic care management from this encompassing package, enabling FQHCs to independently bill for chronic care management through the general care management HCPCS code G0511. This development was met with positivity, and many experts anticipated that a similar segregation would occur for RPM codes shortly thereafter.
The expected timeline for this change turned out to be longer than anticipated, but the adage “better late than never” holds true. In the context of 2024, CMS is presenting a proposal to incorporate RPM and RTM within the G0511 code. This has been a long-standing advocacy, and its realization is a commendable step. Should this proposed alteration be confirmed for 2024, G0511 will encompass:
● Chronic care management
● Principal care management
● Behavioral health integration
● Chronic pain management
● Remote therapeutic monitoring
● Remote physiological monitoring
However, ambiguity and complexity surround the implications of this rule change. Presently, an FQHC can only submit a single G0511 code per month, regardless of the range of care management services provided. Under the proposed framework, it appears that both codes structured around a calendar month (e.g., chronic care management) and those spanning a rolling 30-day period (e.g., RPM device) would be integrated into the one-unit-per-month G0511 code.
This raises the question of whether both device readings and care management time can be maintained concurrently if only one can be billed for each month. FQHCs and RHCs will need to strategize how they will address this situation. Given that G0511 is slated for a slight revaluation to incorporate the new codes, delivering services that cannot be billed for may not be financially viable. Simultaneously, this means that FQHCs can potentially receive higher reimbursement compared to other clinics solely for capturing device data without dedicating time to care management activities.
CMS Restates Established RPM/RTM Regulations
This is where the distinctive aspect of the proposed rule emerges. CMS seized the opportunity to encapsulate some of the ongoing regulations concerning remote monitoring services. These encompass:
● Following the conclusion of the COVID-19 public health emergency (PHE), remote physiologic monitoring (RPM) services must revert to being provided solely to established patients. This category includes individuals who initially received remote monitoring services during the PHE.
● The termination of the PHE also marked the discontinuation of the temporary 2-day RPM billing prerequisite for patients with suspected or confirmed COVID-19 diagnoses. Consequently, the requirement for billing remote monitoring services for all patients has reverted to the 16-day standard.
● Within a 30-day period, only one practitioner is eligible to bill for RPM CPT codes 99453 and 99454, or RTM CPT codes 98976, 98977, 98980, and 98981. This is permissible solely when at least 16 days of data have been collected using at least one medical device.
● In scenarios where patients are furnished with and employing multiple medical devices, the services linked with all such medical devices can only be invoiced once per patient within a 30-day period.
The question arises: Why did CMS find it necessary to explicitly outline these preexisting regulations? As the agency articulated in the proposed rule, “We have received many questions from interested parties about billing scenarios and requests for clarifications on the appropriate use of these codes in general. We believe it is important to share with all interested parties a restatement clarification of certain policies.
What Are the Implications?
It will be intriguing to observe which alterations presented in this proposed rule are ultimately adopted and which ones might be revised or discarded. The introduction of separate reimbursement for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services, particularly when administered by FQHCs and RHCs, would represent a long-awaited victory for a patient demographic that can significantly benefit from remote monitoring.
Regrettably, CMS appears resolute in its stance that a minimum of 16 days’ worth of data must be monitored for certain RPM and RTM codes to be eligible for billing, despite mounting evidence suggesting that fewer days of data transmissions can yield enhanced patient outcomes.
Comments on the proposed rule will be open for submission until September 11, 2023. If you possess strong sentiments regarding any of the proposed alterations pertaining to remote patient monitoring or the numerous other proposed changes associated with remote care management, I strongly urge you to voice your opinions to CMS. Both CMS and Medicare administrative contractors have displayed a willingness to consider the insights of subject matter experts when making determinations about the future of remote care management.
