Remote Patient Monitoring in the 2021 Proposed Medicare Physician Fee Schedule
CMS has now released it’s final 2021 MPFS! Read our overview here.
This article addresses the proposed changes relevant to Digital Health and Remote Patient Monitoring services under the 2021 Medicare Physician Fee Schedule Proposed Rule. For information on proposed changes affecting Telehealth, see our recent article HERE
Remote Patient Monitoring in the 2021 Proposed MPFS: Major clarifications may have implications for RPM business models
Last evening, the Centers for Medicare & Medicaid Services (“CMS”) issued its Proposed Medicare Physician Fee Schedule for CY 2021 (the “Proposed MPFS”). In addition to a number of important changes relating to the provision and reimbursement of telehealth, the proposed MPFS includes long-awaited clarifications around use of the Remote Patient Monitoring (“RPM”) codes established over the past three years. These clarifications, if finalized, may have a significant impact on RPM business models as they have evolved during that time. Below is a summary of the proposed changes and their potential impact on use of RPM as a critical component of patient care.
Who Can Bill for Remote Patient Monitoring?
Since the first standalone reimbursement for RPM was created in the 2018 Proposed MPFS with CPT Code 99091, questions have arisen as to what types of providers can order and bill for RPM service. In the 2021 Proposed Medicare Physician Fee Schedule, CMS clarifies that RPM services are considered Evaluation and Management (“E/M”) services, and that only physicians and non-physician practitioners who are eligible to provide E/M services may bill for RPM. This will be disappointing to physical therapists, occupational therapists, speech language pathologists, LCSWs, and clinical psychologists who are limited in the types of E/M services they are able to independently bill for; to date, the RPM CPT codes are not included as E/M services billable by these practitioners. CMS further clarified that RPM services are not considered diagnostic tests and therefore cannot be billed by and Independent Diagnostic Testing Facility. On a more positive note, CMS confirms in the 2021 Proposed MPFS that RPM services are available to patients with acute conditions (think post-surgical or COVID) as well as chronic conditions.
Patient-Physician Relationship for Remote Patient Monitoring
Prior to the Public Health Emergency (“PHE”) resulting from the COVID-19 pandemic, CMS required that Remote Patient Monitoring could only be ordered and furnished by a physician or practitioner who had an established relationship with the patient. During the PHE, CMS waived this requirement in the interest of increasing access to care when in-person visits were not feasible for patients. The Proposed MPFS reinstates the requirement of a pre-existing patient-physician relationship for RPM services once the PHE ends – meaning that, in to order provide Remote Patient Monitoring services, a physician or practitioner will need to provide an E/M service to new patients, whereby a physical exam and patient history are collected prior to ordering RPM. The Proposed MPFS is not clear as to whether RPM could be ordered as a part of this new patient E/M service, or whether it can only be ordered after the initial E/M visit takes place. It does, however, indicate that an episode of care is defined as “beginning when the remote physiologic monitoring service is initiated and ends with attainment of targeted treatment goals.”
Patient Consent and Initiation of Remote Patient Monitoring Services
Unlike some of the changes discussed above, the 2021 Proposed MPFS would make permanent the change during the PHE that allows patient consent for RPM to be obtained “at the time RPM services are furnished.” The Proposed MPFS goes on to note that the CPT code descriptors for 99453 and 99454 do not specify that clinical staff perform these services, and therefore they are proposing to allow “auxiliary personnel” (non-clinical staff employed, leased or contracted) to furnish the patient education and setup of the device as set forth in CPT Code 99453 and the supply of the device itself as set forth in CPT Code 99454 under general supervision of a physician/billing practitioner. Under the Proposed MPFS, consent may also be obtained by auxiliary personnel under general supervision.
“Medical Device” under CPT Code 99454
The long-standing question as to what type of device must be supplied under CPT Code 99454 has finally been answered in the Proposed MPFS – though the answers may not be what many had hoped for. While the 2021 MPFS confirms that a device need not be “FDA cleared” or “FDA approved,” but must merely meet the FDA’s definition of a “device” for purposes of billing CPT Code 99454, CMS goes on to propose that the device “must be reliable and valid, and that the data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.” Providers who believe that requiring a patient to self-report readings from a device increase their engagement and buy-in to their care will be disappointed that only “connected” devices may be used for purposes of RPM, as will RPM vendors who rely on their “Software as a Device” alone to collect self-reported physiologic data.
“Interactive Communication” and CPT Codes 99457 and 99458
The most surprising aspect of the Proposed MPFS is around the requirement for “interactive communication” as it relates to CPT Codes 99457 and 99458. The American Medical Association’s 2020 CPT Manual states that CPT Code 99457 is for “remote physiologic monitoring treatment management services” and indicates that “Codes 99457, 99458 require a live, interactive communication with the patient/caregiver.” Since the codes were announced in the 2019 MPFS, stakeholders have read this to mean that at least a single live interactive communication is required to bill for these codes, where “live, interactive communication” was not specifically defined. The Proposed MPFS, however, proposes that “interactive communication for purposes of CPT codes 99457 and 99458 involves, at a minimum, 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 over the course of a calendar month for CPT Code 99457 to be reported.” This is a very different interpretation of the codes that will impact business models for RPM companies and will likely be challenged in comments to the Proposed MPFS.
How much data must be collected to bill for CPT Codes 99453 and 99454?
The CPT Manual notes that CPT Codes 99453 and 99454 should not be reported “for monitoring of less than 16 days.” While many had interpreted this requirement to distinguish longer-term remote patient monitoring services from shorter diagnostic services, CMS indicated in the Interim Final Rule issued as a result of the Public Health Emergency that a minimum of two days of data should be collected from a suspected COVID patient in order to bill for RPM. In the Proposed MPFS, CMS clarifies its interpretation of the 16 day requirement, stating that “when the PHE for the COVID-19 pandemic ends, we will once again required that 16 days of data be collected within 30 days to meet the requirements to bill CPT Codes 99453 and 99454.”
How can I provide feedback to the proposed 2021 MPFS?
CMS explicitly states that it seeks comment from stakeholders on “whether the current RPM coding accurately and adequately describes the full range of clinical scenarios where RPM services may be of benefit to patients” and asks whether it would be useful to establish codes that would reimburse RPM services of shorter duration. They also ask for any information on how RPM services are being used in clinical practice. Your comments to the Proposed MPFS can make a difference in the final rule! We urge you to file comments that reflect your experience with RPM, and we are happy to assist you in doing so.
See our posts on the 2019 MFPS and the 2020 MFPS or view our articles on the CMS Interim Final Rule and the Second Interim Final Rule for more content on how to get paid for remote patient monitoring. Watch the recording of our webinar, Telehealth, Remote Patient Monitoring, and Virtual Check-ins during COVID and Beyond.