On Aug. 3, the Centers for Medicare and Medicaid Services (CMS) released proposed changes to the Medicare Physician Fee Schedule for 2021, which includes substantive updates to both remote physiologic monitoring (RPM) and telehealth reimbursement.
During the COVID-19 public health emergency (PHE), CMS loosened regulations on RPM and telehealth in order to increase access to healthcare services. To extend some of these regulations beyond the PHE, President Trump signed the Executive Order on Improving Rural Health and Telehealth Access. Among other things, this order directs the Department of Health and Human Services to create new regulations for permanent telehealth reimbursement for rural healthcare providers.
Proposed RPM Clarifications
CMS proposes that services covered by RPM codes continue to be furnished by auxiliary personnel under general physician supervision.
CMS also proposes the clarification that the medical devices used for RPM must automatically upload patient physiologic data. Thus, patient-reported outcomes cannot be used for RPM services. In addition, the device must be considered “reasonable and necessary” for patient care and “used to collect and transmit reliable and valid physiologic data that allow understanding of a patient’s health status to develop and manage a plan of treatment.”
After the PHE ends, CMS plans to reinstate the requirement of 16 days of data collection within 30 days to bill 99453 and 99454. However, CMS is asking the medical community for comment on other use cases of medical device transmission where fewer than 16 days of data collection and monitoring may be valuable: “For example, a post-surgical patient who is recovering at home might benefit from remote monitoring of his or her body temperature as a means of assessing infection and managing medications or dosage.” They may not need 16 days of monitoring, rather “monitoring several times throughout a day, over a period of 10 days.”
CMS proposes to continue to allow RPM to be furnished for both chronic and acute conditions and for consent to be obtained at the time RPM services are furnished. They also clarify that RPM codes are E/M codes and can only be billed by physicians and non-physician practitioners.
However, after the PHE ends, CMS proposes that RPM be furnished to only established patients. In addition, it proposes to clarify that these services are not considered diagnostic and cannot be furnished by an Independent Diagnostic Testing Facility.
Proposed New Interpretations of RPM
One proposal that has surprised the digital health community is the clarification that the 20 minutes of “interactive communication” required to bill codes 99457 and 99458 be read to mean “synchronous communication,” which would constitute a live phone or video call, at the minimum. The Foley Group writes that this distinction places RPM as “an outlier compared to the other similar designated care management services such as chronic care management services (CCM), for which CMS has been clear that the time-based requirements consist of a combination of patient interactive communication, monitoring, and management of the patient’s care plan.”
Their analysis continues: “The very nature of the RPM code descriptors themselves – which include ‘monitoring and management’ as part of the service – suggests the inclusion of time spent other than purely communication with the patient… if a doctor spent 40 minutes overall doing these activities, but only 19 minutes of that time was actually talking on the phone/video with the patient, the doctor would not be eligible to bill CPT 99457. Such an interpretation does not seem consistent with the use of RPM technology… A more reasonable reading of the code descriptor and intent is that the interactive communication with the patient is part of the 20 minute minimum, but the practitioner can also include time spent reviewing and analyzing the patient’s RPM data and determining how to change the care management accordingly.”
CMS also proposed that, for 99453 and 99454, “even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period.” In previous proposals, this was noted to be per provider, so that both a cardiologist and a pulmonologist would be able to separately bill for RPM if they were each individually monitoring separate devices. However, the proposed fee schedule is unclear whether this would be the case.
Proposed Telehealth Changes
CMS has proposed maintaining select COVID-specific telehealth regulations beyond the PHE to increase patient access. One example is to continue allowing clinicians to conduct telehealth home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home). They are also seeking comment on permanent reimbursement for audio-only interactions.
The Propeller team is monitoring these regulations closely and will keep our Clinical Blog updated with new information relevant to clinicians. If you have questions about how to remotely monitor patients with respiratory conditions, contact us at [email protected].