On November 2, the Centers for Medicare and Medicaid Services (“CMS”) released the 2024 Medicare Physician Fee Schedule (“2024 MPFS”) final rule. 

CMS received over 20,000 comments on the proposed rule, which was published in July. Stakeholders shared examples of digital therapeutics used in remote monitoring and pushed back on CMS’ proposal to classify RPM as “primary care” for purposes of beneficiary assignment under the Medicare Shared Savings Program (“MSSP”). 

Below is a summary of CMS’ responses and final decisions relating to remote therapeutic monitoring (“RTM”) and remote physiologic monitoring (“RPM”).

RTM and RPM, from Proposed to Final Rule: What Changed?

Remote monitoring for established patients

The CMS had proposed that RPM and RTM may be furnished only to established patients. In the final rule, CMS stated that RPM, but not RTM, requires an established patient relationship. This means that any patients receiving RPM services from the end of the Public Health Emergency (“PHE”) forward will need to be established patients before receiving RPM services.

For RTM, CMS noted that they have not specified in previous rules that RTM is limited to established patients but that they expect the billing practitioner to establish a treatment plan prior to providing RTM services. Though it may not be required, it is likely best practice for a billing practitioner to examine a patient and establish a treatment plan prior to beginning an RTM program.

Treatment management codes do not require 16 days of data

In the Proposed 2024 MPFS, CMS suggested that the requirement for transmission of 16 days of data in a 30-day period would be required for additional RPM and RTM treatment management codes 99457, 99458, 98980, or 98981. If finalized, this suggestion would have been a major departure from language in previous rules and the American Medical Association CPT Codebook (“CPT Codebook”), all of which state that the 16-day rule only applies to the device set-up and supply codes 99453, 99454, 98975, 98976, 98977 and 98978.

Commenters urged CMS to reconsider, and CMS confirmed in the 2024 MPFS that the 16-day requirement does not apply to treatment management codes 99457, 99458, 98980, and 98981.

RPM will not be considered “primary care” under the MSSP

CMS proposed categorizing RPM codes 99457 and 99548 as primary care for purposes of beneficiary assignment under the Medicare Shared Savings Program. ACOs and other MSSP stakeholders opposed this during the comment period, fearing it could negatively affect their beneficiary assignment and shared savings.

Stakeholders were concerned that if RPM services were categorized as primary care, specialists and other non-ACO providers that provide RPM could inadvertently divert assigned beneficiaries away from ACOs, disrupting plurality and utilization calculations. CMS acknowledged the feedback and chose not to proceed with classifying RPM as primary care for purposes of MSSP beneficiary assignment.

And…What Stayed the Same?

Concurrent RPM and RTM billing

CMS finalized the rule that RPM or RTM (but not both) may be billed concurrently with the code sets for Transitional Care Management (“TCM”), Chronic Care Management (“CCM”), Behavioral Health Integration (“BHI”), Principal Care Management (“PCM”), and Chronic Pain Management (“CPM”) services.

Stakeholders have continuously encouraged CMS to allow RPM and RTM to be billed concurrently with one another, but CMS finalized its proposal that RPM and RTM cannot be billed in the same month.

That said, language related to using multiple devices in the final rule is still contradictory and indicates that there may be certain scenarios where providers can order RPM and RTM in the same month.

On page 183, CMS states:

This language seems to indicate that although CMS does not expect RPM and RTM to be billed in the same month, there may be unique instances in which it is reasonable and necessary to do so.

Global service payments

CMS finalized its proposal that practitioners may bill and receive separate payment for RPM or RTM during a global service period, “so long as the remote monitoring services are unrelated to the diagnosis for which the global service was performed” and “as long as the purpose of the remote monitoring addresses an episode of care that is separate and distinct from the episode of care for the global procedure.”

This clarifies for stakeholders that there are instances in which providers are permitted to continue monitoring patients’ unrelated conditions and receive separate payment from CMS during a global period. For example, a provider may choose to continue monitoring a diabetic patient’s blood glucose during the period in which that same patient undergoes a hip replacement.

CMS clarified further that practitioners who did not perform the global service and did not receive a global payment may bill for RPM or RTM for any condition within their scope of practice. For example, physical therapists providing RTM to patients following a total hip replacement can bill for RTM during the global period, even if the RTM is related to the hip replacement.

Finally, CMS clarified that providers who perform global procedures and receive global payment cannot receive separate payment for RPM or RTM when the monitoring is directly related to the condition the global procedure addresses.

Supervision requirements

Physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) no longer require direct supervision by a physical therapist (PT)/occupational therapist (OT) as had previously been the case when providing RPM or RTM services. They may now be supervised under the general supervision of PTs/OTs. This is a big win for those in the rehabilitation space.

Payment for RTM and RPM in FQHCs and RHCs

For several years, Rural Health Clinics (“RHCs”) and Federally Qualified Health Centers (“FQHCs”) have asked CMS to include RPM and RTM as separately billable services. This year, the CMS has finalized the decision to allow RHCs and FQHCs to bill HCPCS code G0511 for RPM and RTM services.

Importantly, the code can be billed multiple times in the same month for different care management services, as long as the resource costs associated with each of the services are separately accounted for. The Final Rule does not appear to establish a maximum number of times the code may be billed in a given month.

Key Takeaways

• The 2024 MPFS brings significant wins for FQHCs and RHCs, as well as practitioners providing RTM within PT/OT practices.

• CMS’ clarification on the 16-day rule preserved their existing policy. Most stakeholders would prefer to see the 16-day rule reduced for all codes to account for use cases for which 16 days of data is not medically necessary or clinically validated, but CMS has yet to address such requests.

• Though RPM will not be considered “primary care” for purposes of beneficiary assignment in MSSP, CMS continues to expand its investment in remote monitoring and identify new opportunities to make it available to patients.

For now, remote monitoring remains largely a fee-for-service opportunity under Medicare. However, stakeholders are positioning themselves for value-based payment models where everyone wins, and remote monitoring will likely play an important role.

Looking for more information on how to leverage CMS’ remote monitoring policy or position yourself for success in a value-based setting? We’re here to help!