Proposed Changes to Remote Therapeutic Monitoring Reimbursement in the Proposed 2023 Medicare Physician Fee Schedule
Every summer when the Centers for Medicare and Medicaid Services (“CMS”) releases the Medicare Physician Fee Schedule Proposed Rule (the “Proposed Rule”), the Nixon Gwilt Law (“NGL”) team excitedly opens the two-thousand-something-page PDF and immediately keys “ctrl+F” (or command+F for us Mac users) to jump to our most anticipated section(s). This year, “Remote Therapeutic Monitoring” is where we started!
Stakeholders will be glad to know that CMS continued the RTM conversation with stakeholders beyond last year’s 2022 Medicare Physician Fee Schedule Final Rule (the “2022 Rule”) and directly addressed many of our questions and concerns, including NGL’s recommendations to re-visit the overall code structure to better align RTM with Remote Physiologic Monitoring (“RPM”) and other care management services.
In this year’s Proposed Rule (the “2023 Proposed Rule”), CMS proposed to cease payment for existing RTM CPT codes 98980 and 98981, add four new RTM HCPCS G codes, and add one new RTM CPT code to increase patient access to RTM services and reduce physician and nonphysician practitioner (“NPP”) supervisory burden.
The four HCPCS codes represent monitoring and management services delivered by physicians, NPPs, and qualified nonphysician healthcare professionals (“QHCPs”) and the new CPT code offers reimbursement for the supply of Cognitive Behavior Therapy Monitoring (“CBTM”) devices.
Below is everything stakeholders need to know as you consider submitting public comment to CMS on the proposed changes.
(Why would you submit feedback to CMS? Because during the 60-day public comment period, CMS is required to read every submission before finalizing the proposed rule—your voice will be heard. Your on-the-ground experience goes a long way in helping CMS appreciate the impact of their decisions on access, care, and outcomes.)
Five New RTM Codes
CMS proposed to replace CPT codes 98980 and 98981 with the following four HCPCS codes:
HCPCS code GRTM1: Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes of evaluation and management services
HCPCS code GRTM2: Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver over a calendar month; each additional 20 minutes of evaluation and management services during the calendar month (List separately in additional to code for primary procedure)
HCPCS code GRTM3: Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month
HCPCS code GRTM4: Remote therapeutic monitoring treatment assessment services, additional 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month (List separately in addition to code for primary procedure)
CMS also proposed to adopt CPT code 989X6 for CBTM, described as:
CPT code 989X6: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavior therapy, each 30 days
Proposed Billing Requirements for RTM and Potential Impacts
Whether you are building a business aimed at facilitating RTM for healthcare providers or are growing a direct-to-consumer RTM practice, you know that reimbursement requirements significantly impact several of your most important business decisions, such as product development, hiring appropriate clinical staff, choosing a competitive pricing model, and developing marketing content. Most importantly, these requirements have a direct impact on the value of RTM services for the patients you and your customers serve.
Here’s what you should look out for in the 2023 Proposed Rule:
General supervision of auxiliary staff will be allowed for GRTM1 and GRTM2.
HCPCS codes GRTM1 and GRTM2 are evaluation and management (“E/M”) codes that, if finalized, will be billable by physicians and NPPs (nurse practitioners and physician assistants, among others) otherwise eligible to bill E/M codes. CMS also proposed to designate these two codes as “care management” services to allow for general supervision of auxiliary staff who provide services incident to the billing practitioner. This is a much-needed improvement to the direct supervision requirements for RTM CPT codes 98980 and 98981 and is a direct result of stakeholder feedback to CMS explaining why “general supervision” for staff providing care management services like RTM is critical to a successful business model.
When the RTM codes were introduced last year, stakeholders and CMS alike were, and have since remained, concerned that requiring direct supervision (the default requirement for incident to services provided by auxiliary staff) would overburden billing providers by requiring them to be co-located in the same office suite as auxiliary staff who provide care management activities under their supervision. Importantly, this requirement prevents providers from outsourcing essential care management activities to third-party vendors in the same way they often do for other care management services like Chronic Care Management (“CCM”) and RPM and has resulted in lower-than-anticipated adoption of RTM to date.
CMS’ proposal to remedy the direct supervision barrier is crucial for ensuring that RTM vendors can support overburdened healthcare providers with outsourced clinical staff to assist with monitoring and management activities. Finalizing this proposal will allow for more efficient implementation for providers, thus improving access for patients.
CMS should proactively clarify that auxiliary staff time may be counted towards the 20-minute time requirements for HCPCS codes GRTM1 and GRTM2.
Despite CMS’ clear intent to allow for auxiliary staff to support billing practitioners in the delivery of RTM services, the code descriptors only include “physician or NPP professional time,” which may imply that auxiliary staff time does not count toward the 20-minute time requirement associated with the codes. To eliminate any potential confusion on the issue, CMS should clarify with certainty in the final rule that “auxiliary staff” time does count toward the required 20 minutes for both GRTM1 and GRTM2.
KX Modifier Thresholds (“Therapy Caps”) will apply to HCPCS codes GRTM3 and GRTM4.
GRTM3 and GRTM4 are assessment codes intended to be billed by QHCPs such as physical therapists, occupational therapists, and speech language pathologists, and are therefore classified as “sometimes therapy” in the 2023 Proposed Rule. Importantly, if a therapist bills $3,000 worth or more of Medicare-reimbursable therapy services for one patient during a calendar year, continuing to bill therapy codes for that same patient in that same year may increase the likelihood of a medical review or audit due to monetary caps on therapy reimbursement set forth in the Social Security Act. Continuing to make RTM services subject to applicable therapy caps may serve to discourage providers from ordering the services for fear of reaching or exceeding the $3,000 threshold more quickly, negatively impacting patient access to RTM services.
16 days of data will be required for all four HCPCS GRTM Codes.
In Table 28 on page 409-410 of the 2023 Proposed Rule, CMS proposed to require 16 days of data to be reported before a provider may bill HCPCS codes GRTM1 and GRTM3 for monitoring/treatment management services. This is a new requirement that significantly differs from existing requirements for billing the RTM and RPM services codes. If finalized, providers will only be able to bill the HCPCS GRTM codes once 16 days of data has been transmitted by the patient during the month, even if they spend 20 minutes or more monitoring less than 16 days of data. Importantly, there are numerous clinical contexts for which less than 16 days of data provides valuable insight into a patient’s condition and/or for which 16 days of transmissions are actually clinically contraindicated, and this requirement may result in discontinuation of an RTM program for patients who do not transmit 16 days of data each month but who are still benefiting from the program. If finalized, this requirement will likely reduce adoption/utilization of the RTM codes, particularly in physical therapy and occupational therapy contexts where 16 days of data is often not clinically indicated. CMS will need to clarify this issue for stakeholders in the final rule and consider removing the 16-day requirement to avoid excluding patients who stand to benefit from RTM.
CPT codes 98975 and either 98976 or 98977 must be billed prior to reporting HCPCS codes GRTM1 and GRTM2.
In Table 28 on page 409-410 of the 2023 Proposed Rule, CMS noted that “CPT codes 98975 and 98976 or 98977 must be billed prior to reporting GRTM1 and GRTM2.” CPT code 98975 reimburses providers for set-up and education on use of RTM devices, and CPT codes 98976 and 98977 reimburse for the supply of respiratory and musculoskeletal RTM devices to patients. While it makes sense that devices should be supplied and patients should be educated on the RTM program before providers can collect and monitor data, the practical implications of this language are potentially problematic. For example, it is unclear whether CMS’ language means HCPCS codes GRTM1 and GRTM2 cannot be billed until the second month of monitoring or whether the date of service submitted on claims for the set-up and supply codes must simply be earlier than that of the services code(s). This lack of clarity will likely lead to confusion among providers and additional administrative burden for both MACs and providers in determining the appropriate date of service for claims. CMS will need to clarify the language in Table 28 and specify the appropriate date of service for all RPM and RTM codes to reduce this burden.
CPT code 989X6 will be contractor priced.
CPT code 989X6 is a Practice Expense (“PE”) only code intended to provide reimbursement for RTM devices supplied to patients to monitor a patients’ adherence and response to a prescribed cognitive behavior therapy program. The code appears to mirror existing RPM device supply CPT codes 98976 and 98977 for respiratory and musculoskeletal devices, respectively. While stakeholders will be excited to see CMS expand the types of devices that can be used for RTM, they will be disappointed that CMS declined to create a condition-agnostic device code to capture the broader use cases in which RTM would likely be valuable. Stakeholders may also be disappointed to see that CMS proposed to make CPT code 989X6 contractor priced.
This may lead to inequitable access for patients in different geographic regions and program integrity challenges, such as providers “cherry picking” certain practice locations to obtain higher reimbursement from MACs that pay more than others. If finalized, this will likely also breed uncertainty for RTM vendors, making it difficult to educate providers on reimbursement amounts and to develop a consistent and predictable fee structure for customers. Instead, CMS should crosswalk CPT code 989X6 to CPT codes 98976 and 98977 to protect patients and provide consistency and predictability for healthcare providers delivering CBT monitoring.
Additional Opportunities for Comment
In addition to the issues above, CMS is specifically seeking comments from stakeholders on the following to inform further expansion of RTM:
Devices that meet the “reasonable and necessary” standard under section 1862(a)(1)(A) of the Social Security Act that are not captured in the respiratory, musculoskeletal, or CBT device supply codes;
The types of data that might be collected using RTM devices;
How the data that are collected solve specific health conditions and what those health conditions are;
The costs associated with RTM devices that are currently available to collect RTM data;
How long the typical episode of care for a particular condition type might last; and
The potential number of beneficiaries for whom an RTM device might be used for each health condition type.
Submitting Comments to the Proposed 2023 Medicare Physician Fee Schedule
The questions and issues above underscore the importance of providing feedback to CMS’ regarding the 2023 Proposed MPFS during the public comment period, which ends at 5:00 pm Eastern Time 60 days from the date the Proposed Rule is filed for public inspection in the Federal Register (currently scheduled to be published on July 29, 2022).
Nixon Gwilt has a demonstrated history of assisting clients with submitting public comments and achieving desired results. Contact us to help you draft yours by August 12, 2022 to guarantee your spot in our queue!