The Centers for Medicare & Medicaid Services (“CMS”) released its much-anticipated Proposed Medicare Physician Fee Schedule for CY 2024 (the “Proposed Rule”) on July 13, 2023. This year’s Proposed Rule came later than usual, likely because it includes significant changes and clarifications around how services will be provided going forward since the COVID-19 Public Health Emergency (“PHE”) came to an end on May 11th.

In addition to a modified framework for considering changes to the Medicare Telehealth Services List and some further extensions of telehealth flexibilities, the Proposed Rule has significant implications for other virtual care and care management services, including Remote Physiologic Monitoring (“RPM”) and Remote Therapeutic Monitoring (“RTM”) services. Below is a summary of key provisions in the Proposed Rule relating to RPM, RTM, and other virtual care management services, along with opportunities and challenges for stakeholders in the space.

CMS Proposes “Clarifications” for Remote Monitoring Services

In the Proposed Rule, CMS articulates several clarifications around appropriate use of RPM and RTM services – some that reiterate positions it has taken in the past, another a pleasant surprise, and one rather dismaying. In doing so, CMS also explicitly requests general feedback from stakeholders “that may be useful in further development of our payment policies for remote monitoring services that are separately payable under the current PFS.”

Remote Monitoring for new versus established patients

CMS points to the 2021 MPFS Final Rule in reminding us that with the end of the PHE comes the return of the requirement that RPM and RTM may be furnished “only to an established patient.” However, patients who first received remote monitoring services during the PHE when this requirement was waived are now considered “established patients.”

The “16 days of data” requirement

Despite repeated calls from stakeholders to revisit its position, CMS reiterated that remote “monitoring must occur over at least 16 days of a 30-day period.” This is slightly different than its prior framing requiring 16 days of data transmissions (rather than “monitoring”) in a 30-day period, but it poses the same problem for remote monitoring of patients and conditions that may benefit from less than 16 days of transmission/monitoring. More troubling is CMS’ contention that this requirement also applies to CPT Codes 98980 and 98981 for RTM treatment management services – not just to the supply of device and patient education/setup codes as previously held.

RPM and RTM as complementary to other virtual care management services

In the Proposed Rule, CMS calls out its intent to “allow maximum flexibility for a given practitioner to select the appropriate mix of care management services,” indicating that RPM or RTM (but not both) may be billed concurrently with the code sets for Chronic Care Management (“CCM”), Transitional Care Management (“TCM”), Behavioral Health Integration (“BHI”), Principal Care Management (“PCM”), and Chronic Pain Management (“CPM”) services as long as no time associated with a service is counted twice for another service.

RPM and RTM may NOT be billed for the same patient – or can they??

In confirming that RPM or RTM (but not both) can be billed concurrently with other care management services, the Proposed Rule states that “we propose to clarify that RPM and RTM may not be billed together, so that no time is counted twice by billing for concurrent RPM and RTM services.” It then goes on to say that “[i]n instances where the same patient receives RPM and RTM services, there may be multiple devices used for monitoring, and in these cases, we will to [sic] apply our existing rules, which we finalized when establishing the RPM code family, meaning that the services associated with all the medical devices can be billed by only one practitioner, only once per patient, per 30-day period, and only when at least 16 days of data have been collected.” This proposed clarification seems contradictory unless CMS is suggesting that RPM and RTM may be billed for the same patient when ordered by different practitioners. Further clarification in the Final Rule would be helpful.

Separate payment for global surgery periods

CMS is now officially clarifying that RPM or RTM services may be furnished and reimbursed separate and apart from the global services payment for surgery as long as “other requirements for the global service and any other service during the global period are met.”

Separate payment for RTM and RTM in FQHCs and RHCs

For years, Federally Qualified Health Centers (“FQHCs”) and Rural Health Clinics (“RHCs”) have asked CMS to allow separate RPM and RTM payments, to no avail. This year, CMS is finally proposing to change that by allowing RHCs and FQHCs to bill HCPCS code G0511 for RPM and RTM services.

RPM to be considered “Primary Care services” under the Medicare Shared Savings Program

CMS is proposing to classify CPT codes 99457 and 99548 as primary care services under the Medicare Shared Savings Program (“MSSP”) for purposes of determining beneficiary assignments to an MSSP ACO.

Request for Information on Digital Therapies, RPM, and RTM

In the Proposed Rule, CMS issues a broad request for information from stakeholders to better understand “the opportunities and challenges related to our coverage and payment policies,” particularly in regard to the types of practitioners and staff involved in furnishing RPM and RTM services, how these services are used in clinical practice, experience with coding and payment policies for these services, challenges around claims processing, the need for further practitioner education and guidance around remote monitoring, and opportunities for future rulemaking around remote monitoring services. CMS is also interested in the potential interplay between RTM for Cognitive Behavioral Therapy and other digital CBT services. The Proposed Rule notes that past commenters (including us here at Nixon Gwilt Law) have supported the concept of a generic RTM device code similar to the generic supply of device code for RPM, and requests information on the advantages and disadvantages of such a code along with thoughts on how the code should be valued.

Key Takeaways

• Standalone reimbursement for RPM and RTM services when provided by FQHCs and RHCs is a long-awaited win for providers, patients, and digital health companies. Another big win is the clarification that RPM and RTM are separately payable when provided in the context of a global surgical period.

• In the loss column -- CMS seems to be holding firm on its contention that 16 days of data should be monitored in order for certain RPM and RTM codes to be billed despite evidence that fewer days of data transmissions can improve patient outcomes.

• This Proposed Rule provides many opportunities for stakeholder feedback on policies relating to RPM and RTM, so now is the time to make your voice heard!

 If you are interested in submitting comments to this Proposed Rule, we’re here to help! The comment period ends in 60 days, so please contact us as soon as possible to learn more.