Remote Patient Monitoring in the 2021 Medicare Physician Fee Schedule: The good, the bad, and the ugly
On December 1, 2020, the Centers for Medicare and Medicaid Services (“CMS”) released its Final Medicare Physician Fee Schedule for 2021 (the “Final 2021 MPFS”), revising payment policies for services provided to Medicare beneficiaries by medical practitioners. These policies will take effect on January 1, 2021.
The Final 2021 MPFS contains numerous interpretations and clarifications relating to Remote Patient Monitoring (“RPM”) care management services that will change the way RPM has been implemented in medical practices since 2018, when standalone reimbursement for RPM first became available. Some of these changes are positive, making permanent policies that were enacted on an interim basis during the COVID-19 Public Health Emergency (“PHE”). Other policy interpretations miss the mark and are likely to result in under-utilization by physicians of RPM, to the detriment of patients who would otherwise stand to benefit from RPM as a care management service. Below are some highlights of policies relating to Remote Patient Monitoring as set forth in the Final 2021 MPFS.
The Good
CPT Code 99457 and “treatment management services, 20 minutes or more”
By far the most controversial interpretation around RPM in the Proposed 2021 MPFS involved language in the code descriptor for CPT Code 99457 describing “20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.” CMS proposed to interpret this language as requiring “at a minimum, a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission,” and further that “the interactive communication must total at least 20 minutes of interactive time with the patient” during the month.
Stakeholder organizations, RPM companies, and physicians alike were unified in opposing this interpretation, finding no basis for it when the code was promulgated by the American Medical Association’s CPT Committee and pointing out that such interpretation was not in keeping with similar time requirements for the Chronic Care Management (“CCM”) codes, another care management services code set. Stakeholders further argued that requiring 20 minutes of live audio communication with an RPM patient on top of time spent on all other care management services involved in RPM would render the RPM business model infeasible at the current reimbursement rates and would be impractical for patients. CMS responded by changing its proposed interpretation and instead clarifying that the 20 minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.
Patient Consent for RPM
CMS made permanent its policy established during the COVID-19 PHE allowing patient consent for RPM services to be obtained at the time of service, rather than prior to commencement of the service.
Patient Education and Setup, Supply of Device
CMS also finalized a COVID-19 PHE policy permitting all auxiliary personnel (including but not limited to clinical staff) to provide education on RPM services to patients and setup of the RPM device(s) under CPT Code 99453. Auxiliary personnel can be contracted or employed by the billing practitioner, meaning RPM vendors can build this service into their existing offerings to further ease the burden on physician customers.
RPM for “established patients”
While CMS declined to make permanent the COVID-19 PHE policy allowing RPM services to be ordered by a physician for a new patient, it did clarify that a physician-patient relationship could be established by a prior E/M service and did not specify that such service must occur via an in-person visit rather than by telehealth.
The Bad
RHCs and FQHCs
CMS once again declined to extend standalone reimbursement for RPM services to Rural Health Clinics (“RHCs”) and Federally Qualified Health Centers (“FQHCs”), effectively ensuring that many of the patients most in need of these critical services will not have access to RPM. CMS contends that reimbursement for these care management services is encompassed in the All-Inclusive Rate for RHCs and the Prospective Payment System for FQHCs, ignoring and contradicting the fact that other care management services like CCM have been deemed eligible for standalone reimbursement.
RPM by Therapists
CMS declined to eliminate a barrier to services for patients undergoing physical, occupational, or behavioral health therapy, failing to address comments by numerous stakeholders requesting that such therapists be permitted to order RPM for patients using “sometimes therapy” codes similar to those created for therapists to bill e-visits and virtual check-ins. Instead, CMS reiterated that RPM services may only be ordered and billed by physicians, nurse practitioners, or physician assistants.
The Ugly
Transmission by connected devices
CMS finalized its interpretation requiring use of “connected” devices (e.g. Bluetooth, wi-fi, or cellular-enabled peripheral devices) to transmit patient data rather than allowing patients to manually enter their physiologic readings by a devices into a SaaS platform for remote transmission, citing concerns about data integrity and validity. In doing so, it ignored comments by stakeholders pointing out that such an interpretation would eliminate relevant physiologic metrics that are typically self-reported, such as pain and mood, from use in managing a patient’s care. CMS also failed to consider the lack of access to certain types of devices in “connected” form that became especially apparent during the COVID-19 PHE, when we experienced a global shortage of these devices.
16 days of data transmissions
In its proposed fee schedule, CMS requested comments from stakeholders as to whether fewer than 16 days of data transmissions by a patient in a given month would be still be useful in monitoring and care management of certain conditions. Numerous stakeholders responded with clinical examples of such conditions that could readily be managed with fewer data transmissions, and even some instances in which requiring 16 separate transmission can be damaging to patients – for example, transmission of a patient’s weight in managing obesity. Despite these specific examples, CMS stated in the Final 2021 MPFS that “although we received general support for a reduction in the number of days of data collection required to bill for CPT codes 99453 and 99454, we did not receive specific clinical examples…we are not extending the interim policy to permit billing for CPT codes 99453 and 99454 for fewer than 16 days in a 30-day period.” Notably, the Final 2021 MPFS does not appear to prohibit billing CPT codes 99457 and 99458 when 20 minutes of care management services time has accrued during a calendar month, regardless of whether or not 16 days of transmissions have occurred during that time.
The Big Takeaway
In its Final Rule, CMS did not directly address many of the issues relating to RPM raised by stakeholders in comments. The new interpretations and clarifications set forth in the Final 2021 Medicare Physician Fee Schedule relating to Remote Patient Monitoring will require most RPM companies and medical practices to modify their business models and operations to incorporate these changes. Please contact us for assistance in doing so.
This post is the first in a series of posts breaking down the changes relating to digital health in the 2021 MPFS. Stay tuned for more information about changes related to telehealth, virtual communications services, and more. For additional information about the Final 2021 Medicare Physician Fee Schedule, please contact us.
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