Key Takeaways for Remote Therapeutic Monitoring in the Final 2023 Medicare Physician Fee Schedule: “General Supervision for all RTM”
As it does every Fall around this time, the Centers for Medicare and Medicaid Services (“CMS”) released its final version of the Medicare Physician Fee Schedule for 2023 (the “Final 2023 MPFS”), the regulatory Rule governing Medicare payment and coverage policies for physician services. The Final 2023 MPFS includes highly anticipated updates to CMS policies governing reimbursement for Remote Therapeutic Monitoring (“RTM”) services under the new CPT code set introduced in 2022.
Below is an overview of what will change in 2023, for better and for worse.
But first, a brief reminder of how we got where we are today:
In early July, CMS released its draft version of the MPFS for 2023 (the “Proposed 2023 MPFS”), which included changes to payment policy for RTM services aimed at addressing some of the concerns posed by the existing CPT Code set as established by the American Medical Association’s CPT Committee.
At the heart of these concerns was placement of the CPT Code set for RTM in the Medicine section of the CPT Manual which, in addition to physicians, nurse practitioners, and physician assistants, allowed practitioners such as physical therapists and clinical psychologists to independently order and bill for RTM services.
CMS concluded in the 2022 Medicare Physician Fee Schedule that, by placing these codes in the Medicine section rather than the E/M services section of the CPT Manual, the RTM codes could NOT be “designated care management services” codes that allow for time spent by clinical staff to be billed “incident to” a practitioner’s services under “general supervision” – meaning that billing practitioners would need to exercise “direct supervision” over clinical staff by being present in the same physical location. This direct supervision requirement distinguished RTM from other remote monitoring and care management services like Remote Physiologic Monitoring (“RPM”) and Chronic Care Management (“CCM”), causing concern among stakeholders that the requirement would stifle adoption and limit patient access to RTM.
What changed for Remote Therapeutic Monitoring from the Proposed Rule to the Final Rule?
We have noted in the past that the ability for medical practices to outsource the monitoring/treatment management component of care management services, including RTM programs, to clinical staff external to their own practice is viewed as critical for the success of these programs.
The Proposed 2023 MPFS sought to remedy the problem presented by the two RTM treatment management services codes finalized in 2022 by replacing CPT codes 98980 and 98981 with four new HCPCS codes for treatment management services – two for use by physicians, nurse practitioners, and physicians assistants as designated care management services (HCPCS GRTM1 and GRTM2) that may be provided by clinical staff under the general supervision of the billing practitioner, and two for use by Qualified Health Care Practitioners (HCPCS GRTM3 and HCPCS GRTM4) such as physical therapists, occupational therapists, and clinical psychologists.
In the Final 2023 MPFS, CMS decided NOT to finalize these new HCPCS codes, stating:
“We believe some interested parties may have misinterpreted our proposed valuation of the G-codes, GTRM-3 and GTRM-4. Specifically, we received comments that misunderstood our proposed valuation for GTRM-3 and GTRM-4 to mean that we proposed an across-the-board cut to payment for all Medicare Part B payment for certain types of non-physician practitioners that current[ly] may bill the RTM treatment management codes (CPT codes 98980 and 98981). Based on public comments, we agree that confusion remains about how the new G-codes, if finalized, would or would not possibly create a chilling effect on the availability of RTM services.”
“General Supervision for all RTM”
Instead, CMS chose to focus its changes on the supervision levels required for clinical staff involvement in an RTM program, stating “General supervision for all RTM services. Any RTM service may be furnished under our general supervision requirements.”
CMS does not attempt to rectify its previously expressed concern that general supervision is not permissible for non-E/M services codes. While this change will certainly benefit Medicare practitioners eligible to bill “incident to,” this change may not supersede the existing “incident to” prohibition for services provided incident to a therapist. Interestingly, Chapter 15, Sec. 230.5 of the Medicare Benefit Policy Manual states: “Incident to a Therapist. There is no coverage for services provided incident to the services of a therapist.”
It is therefore unclear how the policy change in the 2023 Final MPFS permitting general supervision for all RTM services will benefit non-physician Qualified Health Care Practitioners like physical therapists and clinical psychologists.
The 16-Day Requirement for Remote Therapeutic Monitoring
In the Proposed 2023 MPFS, CMS suggested for the first time that, under the new proposed HCPCS codes GRTM1-GRTM-4, 16 days of data transmissions would be required in order to bill ANY/ALL of the RTM codes, not just the initial set-up and device supply codes as the current rules provide. Understandably, this sparked significant concern among stakeholders who see value in providing treatment management services with fewer than 16 days of data transmitted.
Given CMS’ decision not to finalize the new proposed codes, it appears that this new requirement is now off the table, at least for the time being, and that the 16-day requirement will continue to apply only to RTM CPT codes 98975, 98976, and 98977.
In the Final 2023 PMFS, CMS clearly signals that it expects continued modification of the RPM and RTM code sets, pointing to the CPT Committee’s reported upcoming consideration of new CPT codes requiring less than 16 days of data collection.
No Generic Supply of Device Code
Unlike the generic device supply CPT code 99454 for supply of Remote Physiologic Monitoring (“RPM”) devices implemented by CMS in 2019, CMS in 2022 finalized two system-specific device codes for RTM – CPT code 98976 for supply of a device to monitor the respiratory system, and CPT code 98977 for supply of a device to monitor the musculoskeletal system. In both the 2022 and the 2023 Proposed MPFS, commenters urged CMS to create a generic device supply code that is condition/system agnostic to allow for additional valuable use cases for RTM services.
CMS has declined to do so once again, stating “it remains unclear whether a generic device code would be administrable as a permanent policy, for many reasons” and “it may be difficult to establish an appropriate valuation for a single device code that would reflect the myriad of possible applicable devices.” This reasoning is somewhat curious given the successful use of a generic device code for RPM services during the past four years. However, CMS notes that it will continue to engage with stakeholders on this issue, leaving the possibility open for a generic RTM device code in the future.
New Cognitive Behavioral Therapy Device Code
CMS did open the door a bit wider for additional RTM use cases by finalizing a new RTM device supply code for Cognitive Behavioral Therapy Monitoring, CPT code 989X6. Unfortunately, CMS declined to assign a national reimbursement amount to this code, opting instead to allow the individual Medical Administrative Contractors (the “MACs”) to determine whether/how to reimburse the code.
The Big Takeaways
CMS’ broad declaration of “General Supervision for all RTM” in the 2023 Final MPFS is a big step forward for RTM services providers and medical practices who want to implement effective Remote Therapeutic Monitoring programs to improve patient outcomes.
While utilizing outsourced clinical staff for monitoring and treatment management services under general supervision of the billing practitioner should be straightforward for physicians, nurse practitioners, and physician assistants, there may be some confusion around how, if at all, this declaration may impact other Qualified Health Care Providers such as PTs, OTs, and psychologists.
The new RTM device supply code for Cognitive Behavioral Health monitoring is likely to be underutilized due to uncertainty around whether local MACs will reimburse for the code; a generic device code would likely have a greater impact on expanding use cases for and adoption of RTM service programs.
Fortunately, CMS has signaled its willingness to work with stakeholders to address continuing concerns around the CPT code set and payment policies for RTM services.
The 2023 Remote Therapeutic Monitoring CPT Codes
CPT code 98975: Initial Set-up and Patient Education (Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment)
CPT code 98976: Supply of Device for Monitoring Respiratory System (Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days)
CPT code 98977: Supply of Device for Monitoring Musculoskeletal System (Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days)
CPT code 989X6: Supply of Device for Cognitive Behavioral Therapy Monitoring (Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, cognitive behavioral therapy, therapy adherence, therapy response); initial set-up and patient education on use of equipment; device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavioral therapy, each 30 days)
CPT code 98980: Monitoring/Treatment Management Services, first 20 minutes (Remote therapeutic monitoring treatment management services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes)
CPT code 98981: Monitoring/Treatment Management Services, each additional 20 minutes (Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure))
Stay tuned for more on that when we have it and contact us to learn more!
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