CMS Expands Medicare Coverage for Remote Patient Monitoring

The Centers for Medicare & Medicaid Services has added new codes to its 2022 Physician Fee Schedule that will enable care providers to be reimbursed for more home-based services.

Health systems are looking at remote patient monitoring as an emerging piece of the care delivery puzzle, but they need help embracing the strategy. Recent moves by the Centers for Medicare & Medicaid Services to improve coverage are a step in the right direction, but experts say the effort is still very much a work in progress.

Remote patient monitoring, or RPM, is a relatively new concept, though its roots trace back a few decades to the concept of connecting with patients at home between visits to the clinic or doctor's office. The platform involves connecting with patients at home to track key health metrics, such as vital signs, to shape and modify care management. Providers often use mHealth devices to collect and transmit that data and telehealth platforms to analyze the results and communicate with the patient.

RPM was thrust into the spotlight during the pandemic, when providers sought to push more care services out of the hospital and into the home. Now they're looking to continue that momentum, and to develop use cases that work well for a variety of patients, including those who have been discharged from the hospital and those with chronic care management needs.

CMS first recognized remote patient monitoring in 2019, with a handful of CPT codes aimed at covering remote physiological monitoring, or the gathering of physiological data—such as heart rate, blood pressure and blood sugar—from patients at home. Those codes—also called RPM—have been tweaked each year to expand coverage incrementally, and with the recent release of the 2022 Physician Fee Schedule, CMS is adding new coverage for what it calls remote therapeutic monitoring (RTM), or the tracking of certain non-physiological data, such as medication or therapy response and adherence and pain level.

Healthcare providers and remote patient monitoring advocates hailed the RTM codes as a step in the right direction when they were proposed earlier this year, but many said the coverage was incomplete and confusing. With the final rule released this month, some of those concerns were addressed. But not all.

"It is definitely a step in the right direction," says Carrie Nixon, Esq., a co-founder and managing partner in the Nixon Gwilt law firm and an expert in healthcare innovation. "And there is absolutely more to be done."

"While CMS in the Final Rule explicitly adopted important portions of this framework by expanding 1) the types of patient data captured and analyzed for remote monitoring, and 2) the types of practitioners who can order and bill for remote monitoring, it stopped short of fully aligning RPM and RTM, stating: 'In the interest of coding efficiency for these services, we hope to continue to engage in dialogue with stakeholders, including the AMA CPT, in the immediate future on how best to refine the coding for the RTM services to address some of the specific concerns raised by stakeholders,' " she said in a recent online analysis of the new codes. "This language leaves room for hope that remote patient monitoring stakeholders will not be forced to wait another full year for improvements to policy around RPM and RTM."

New Codes for Remote Therapeutic Monitoring

The RTM codes to be included in the 2022 PFS are as follows:

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 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; and

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).

Some Good (And Not So Good) Reactions 

One of the criticisms of the RTM codes is that they don't cover enough conditions. In a recent analysis, Nathaniel Lacktman, a partner with the Foley & Lardner law firm and chair of its Telemedicine & Digital Health Industry Team, and Thomas Ferrante, a partner and member of that team, point out that the RTM device supply codes (98976 and 98977) are limited to monitoring the musculoskeletal and respiratory systems and don't take into account, for example, neurological, vascular, endocrine, or digestive concerns.

"In the final rule, CMS acknowledged it received comments that a general device code should be created that would be system-agnostic and not restrict RTM reimbursement to monitoring patients' musculoskeletal and respiratory systems, (but the agency) did not include such a general device code in the final rule," the two wrote, adding that they're optimistic that CMS will expand that list in the future.

"That is craziness," Nixon says, noting there are many more opportunities for remote patient monitoring that extend beyond musculoskeletal or respiratory care management.

"In its final rule, CMS discusses RTM in the context of 'therapy adherence' and 'therapy response,' " she wrote in her analysis. "CMS further references monitoring of 'health conditions, including musculoskeletal system status, respiratory system status,' where 'non-physiologic data' is collected. While 'health conditions' can be interpreted broadly, the focus on 'musculoskeletal system status' and 'respiratory system status' comes into play with the two device codes, which may be interpreted as limiting reimbursement for 'device supply' to devices related solely to those two systems. CMS should rectify this with a system-agnostic device code as soon as possible to allow reimbursement for RTM services beyond monitoring patients' musculoskeletal and respiratory systems."

Nixon, Lacktman, and Ferrante also note that the RTM codes are classified as general medicine codes, rather than evaluation and management (E/M) codes, which is how the RPM codes are classified. This means they can't be used for care management services, or for services that are ordered by a physician and carried out by non-physician practitioners. So, while physicians can leverage their staff to manage RPM services, they must do the RTM monitoring themselves to qualify for Medicare reimbursement.

Nixon points out that the two sets of codes can be confusing. Healthcare providers are under a lot of pressure, and many would like to delegate or even outsource some remote patient monitoring services, thereby improving patient monitoring and care and avoiding workflow stress. They can't do that with RTM codes, which require their participation. And while many new providers can take advantage of the RTM codes, they'd like to use the RPM codes to collect data, but can't.

"There are cases where that's absolutely relevant," she says. "It would be very useful to allow these practitioners to be able to bill for RPM. … That's where we need alignment."

In any case, RTM codes do open the door to more care providers using the platform, including physical and occupational therapists, speech and language pathologists, physician assistants, nurse practitioners, and clinical social workers.

"In the final rule, CMS stated the primary billers of RTM codes are projected to be psychiatrists, nurse practitioners, and physical therapists," Lacktman and Ferrante note in their analysis. "The new RTM codes, classified as general medicine codes, should open up opportunities for therapists, psychologists, and other eligible practitioners who cannot currently bill for RPM."

In addition, CMS has amended the RTM codes in the final rule to allow self-reported data, or information either reported by the patient or uploaded by the patient into the monitoring device, as long as the device meets the U.S. Food and Drug Administration's definition of a medical device or a smartphone app or online platform defined as software-as-a-medical device (SaMD). This differs from the RPM codes, which require that data be collected and uploaded digitally, without any patient participation.

Looking to the Future

The codes give healthcare providers some reimbursement for new RPM services, and they represent a subtle step forward. And they fall in line with CMS' line of thinking, which has always been that it wants to see proof that these technologies improve clinical outcomes and reduce wasteful expenses before they're embraced by federal regulators.

The challenge is that CMS is taking a piecemeal approach to RPM and providing two different sets of codes that don't mesh well together.

"On the one hand, it's great that there's acknowledgement that there are different types of data" to be gathered in remote patient monitoring programs, Nixon says. "On the other hand, this piecemeal approach is inhibiting" RPM adoption.

She says CMS has signaled more of an interest this past year in working with stakeholders, something the agency had been criticized for avoiding in the past. She's hoping for that discussion soon on how to better align RPM and RTM codes.

"I really don't want to wait another year for that to happen," she says.