As the adoption of telehealth, remote monitoring, and connected care technologies continues to increase, it’s important for healthcare leaders to stay on top of the latest updates in telehealth reimbursement. 

Some of the most significant updates come from the Centers for Medicare & Medicaid Services (CMS), which released its final rule for Medicare payments under the Physician Fee Schedule (PFS) in 2024. Let’s delve into the eight key updates impacting telehealth and remote patient monitoring (RPM) services:

1. Established Patient Requirement: A fundamental change concerns new patients seeking RPM services. Before initiating these services, a new patient evaluation and management (E/M) or similar service is now mandatory. This ensures a clear care plan is established during an in-person visit. However, exceptions exist for patients who utilized RPM during the Public Health Emergency (PHE) as they already have an established patient-provider relationship. Additionally, this established patient rule doesn’t apply to remote therapeutic monitoring (RTM) reimbursement.

2. 16-Day Data Collection for RPM: The billing guidelines for RPM data collection have been revised. Now, healthcare providers need to collect data for at least 16 of the 30-day episode of care period, excluding calendar month days, for CPT codes 99453 and 99454. This clarifies the data collection requirements for accurate reimbursement of these specific codes.

3. Clarity on RPM/RTM “Time Spent”: CMS has provided further clarity regarding time spent billing guidelines for specific CPT codes. Codes 99457, 99458, 98980, and 98981, representing “time spent” for treatment management, are not subject to the 16-day data collection requirement. They maintain their existing billing guideline of a 30-day calendar month.

4. One Provider for RPM/RTM Billing: A significant update concerns the number of providers permitted to bill for RPM and RTM services. According to the new guidelines, only one provider can bill for either RPM device codes (99453 and 99454) or RTM codes (98976, 98977, 98980, and 98981) within a 30-day episode of care. This means the provider who submits the claim first will be reimbursed, whereas subsequent claims from other providers for the same patient during that period will be denied.

5. Concurrent Billing with Other Services: Reimbursement for RPM and RTM cannot be combined with similar services within the same month. However, specific services like Chronic Care Management (CCM), Transition Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Chronic Pain Management (CPM) can be billed concurrently with either RPM or RTM.

6. Billing During Global Surgery Periods: The 2024 Physician Fee Schedule clarifies the permissible timeframe for billing RPM/RTM services during a surgical global period, defined as the time during which a physician cannot bill for related office visits. Now, if the billing provider for RPM or RTM services is different from the provider receiving the global payment, these services can be billed. Additionally, if RPM or RTM services were already in place before the surgery, CMS allows payment outside the surgical global period.

7. FQHCs and RHCs Gain Reimbursement: This update presents new opportunities for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). They can now receive reimbursement from CMS for either RPM or RTM services (not both) when billed alongside Care Management CPT code G0511. This code can be billed multiple times per calendar month, offering additional financial support for these healthcare facilities.

8. New Cost Fee Structure: The final update concerns changes to the cost fee structure. While the specific details are outside the scope of this article, it’s important to be aware that individual CPT code reimbursement rates for RPM, CCM, and RTM have been slightly adjusted.

These updates highlight the ongoing evolution of telehealth and remote patient monitoring regulations. By staying informed about these changes, healthcare providers and facilities can ensure they are delivering compliant and reimbursable care to patients while optimizing their practice efficiency.

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If you are a medical professional interested in leveraging remote technology to optimize patient health, this guide outlines remote therapeutic monitoring codes for 2024 and how to bill using RTM CPT codes. Remote therapeutic monitoring (RTM) is similar to remote patient monitoring. However, RTM is used to acquire non-physiological patient data for the respiratory and musculoskeletal systems.

This data can monitor medication and exercise adherence, functional status, response to therapy, and musculoskeletal and respiratory activity. Patients use RTM devices to collect health data for musculoskeletal and respiratory system status, therapy, and medication response and adherence. Unlike in remote patient monitoring CPT Codes, the RTM patient data is self-reported and communicated to their physician. 

Remote Therapeutic Monitoring Codes

Healthcare providers can improve patient outcomes while establishing additional revenue streams with an established and efficient remote therapeutic monitoring service model. However, it is essential to note that regulations exist regarding which remote therapeutic monitoring codes can be billed together with remote patient monitoring. Providers are not allowed to double bill for RTM and RPM.

In 2022, The Center for Medicaid and Medicare (CMS) established remote therapeutic monitoring codes to help make billing for physical, occupational, and speech-language pathologists more accessible. Before 2022, these qualified healthcare professionals were not reimbursed for collecting data and educating patients using remote health devices. These new RTM CPT codes allow healthcare systems to increase revenue while improving patient outcomes and recovery programs.

RTM CPT codes are general management codes that qualified healthcare professionals, like physical and occupational therapists, can use to bill for their services, unlike RPM codes. The most commonly used RTM devices are a scale and spirometer. The 2024 RTM CPT codes, descriptions, payment rates, and billing frequency are listed below. 

2024 Remote Therapeutic Monitoring Codes

In this section, you will find a quick overview of remote therapeutic monitoring codes for 2024. All remote therapeutic monitoring services can be provided under general supervision. Physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) can provide RTM services. RTM CPT codes can be used for “sometimes therapy,” allowing physicians, nurse practitioners, physician assistants, and clinical nurse specialists to perform RTM. 

CPT Code 98975

This code covers initial setup and patient education on the use of equipment. It can be billed once by one practitioner only when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT 98975 is $19.65.

Respiratory CPT Code 98976

Billing CPT code 98976 pays for respiratory devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the respiratory system. The code can be used every 30 days by one practitioner only when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98976 is $46.83.

Musculoskeletal CPT Code 98977

Code 98977 reimburses musculoskeletal devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the musculoskeletal system. This can be billed once every 30 days by one practitioner only when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98977 is $55.72.

CPT Code 98980

RTM CPT code 98980 bills for the initial 20 minutes of treatment time per calendar month. Time must include at least one interactive communication via phone or video with the patient during the month. New in 2023, CPT 98980 can be billed “incident to” or under general supervision. CPT 99457 is billed every 30 days. The average national payment rate for CPT 98980 is $49.78.

CPT Code 98981

In 2024, CPT 98981 covers each additional 20 minutes of treatment time per calendar month. It requires at least one interactive communication during the calendar month. This code has the exact requirements as CPT 98980.  The average national payment rate for CPT 98981 is $39.30.

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In this article, you’ll learn the differences and rates between RTM billing codes and RPM billing codes for 2024. CMS released the CY 2024 Physician Fee Schedule Final Rule in November 2024. The final rule includes 3,000 pages of detailed policy changes related to remote therapeutic monitoring (RTM) and remote patient monitoring (RPM) Medicare reimbursement. This article breaks down the final rule and provides key takeaways for the RTM billing codes and RPM policy updates, set to begin on January 1, 2024. 

RPM and RTM Billing Codes in 2024

Remote therapeutic monitoring (RTM) and remote patient monitoring (RPM) remote track and report on non-physiological patient data, including vital signs, medication and exercise adherence, functional status, response to therapy, and respiratory and musculoskeletal activity. Understanding the billing codes for these new remote care services can be confusing.

Remote therapeutic services allow patients to receive treatment guidance, support, and interventions outside the traditional in-office setting. These services may include counseling via video chat, text messaging programs aimed at medication adherence, virtual physical therapy sessions, and more. The goals are to increase access to care and improve outcomes.

New revenue streams opened to healthcare providers in November 2022 when the American Medical Association (AMA) created 5 CPT codes for RTM services: 98975, 98976, 98977, 98980, and 98981. The codes comprise three practice expense-only codes: 98975, 98976, and 98977, and two codes for treatment management: 98980 and 98981.

Remote patient monitoring allows providers to track vital signs, symptoms, medication adherence, and more outside of the office. This aims to detect early warning signs and prevent bigger problems. The billing codes for RPM are: 99453, 99454, 99457, 99458, and 99091.

Now that we’ve reviewed what remote therapeutic monitoring is, we will provide a quick overview of billing updates for 2024. 

RPM and RTM Billing Codes 2024

The 2024 Physician Fee Schedule Final Rule provisions clarify remote therapeutic monitoring services requirements. The codes account for the extra time needed for planning, data analysis, and interacting with patients outside of direct contact. Overall, there are a few key takeaways regarding RTM billing codes in 2024. 

Only One Provider Bills in RTM and RPM

CPT codes 99453 and 99454 and RTM billing codes 98976, 98977, 98980, and 98981 may be billed by only one clinician over a 30-day period. This is per episode of care and not per calendar month.  Therefore, if more than one provider bills for RPM or RTM services in the same month, the first provider to submit the claim will be reimbursed. The other claim (s) will be denied. 

RPM and RTM Billing Codes and Other Services 

RPM and RTM cannot be billed together during the same month. However, some services can be billed with either RPM or RTM concurrently. These are as follows:

• Chronic Care Management
• Transition Care Management
• Behavioral Health Integration
• Principal Care Management
• Chronic Pain Management

Global Surgery Period

A global period is when a physician can not bill for related office visits. However, RTM and RPM services are permitted when the billing provider of the services is not the provider who receives the global service payment. When a patient receives RTM or RPM services before a surgical procedure, CMS will pay for the RTM or RPM services outside of this global period.

FQHCs and RHCs 

The 2024 Physician Fee Schedule allows new reimbursement opportunities for FQHCs and RHCs, allowing them to receive reimbursement for RPM and RTM services. However, only one of these services can be billed under CPT code G0511. Furthermore, it can be billed multiple times each calendar month at the rate of $72.98.

The following section explains exactly what the 5 RTM billing codes cover in 2024, including the average reimbursement rate and requirements.

RTM Billing Codes and Reimbursement Rates for 2024

As of 2022, CMS adopted 5 RTM billing codes to pay for device setup, collection, interpretation, and processing of remote non-physiological data. The following section explains exactly what the 5 RTM CPT codes cover in 2024, including average reimbursement rate and requirements. These rounded numbers are based on non-facility national averages and vary by region.

98975

This code covers initial setup and patient education on the use of equipment. It can be billed once in a 30-day period when at least 16 days of data is collected on at least one medical device. The average national payment rate for CPT 98975 is $19.65.

98976

Billing CPT code 98976 pays for respiratory devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the respiratory system. The code can be used every 30 days when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98976 is $46.83.

98977

Code 98977 reimburses musculoskeletal devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the musculoskeletal system. This can be billed once by one practitioner only when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98977 is $46.83.

98980

CPT 98980 bills for the initial 20 minutes of treatment time per calendar month. Time must include at least one interactive communication via phone or video with the patient during the month.

CPT 98980 can be billed “incident to” or under general supervision, which includes physicians, nurse practitioners (NPs), and physician assistants (PA). CPT 99457 is billed monthly. The average national payment rate for CPT 98980 is $49.78.

Notably, billing is not generally part of the Medicare benefit for qualified healthcare practitioners: physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs). Second, RTM services must be personally furnished by the billing qualified health care practitioner. When the practitioner is a PT or OT, a therapy assistant must be under the supervision of the OT or PT.

CPT 98981

In 2024, CPT 98981 covers each additional 20 minutes of treatment time per calendar month. This code has the exact requirements as CPT 98980.  The average national payment rate for CPT 98981 is $39.30.

What are the differences between RTM and RPM?

Remote patient monitoring (RPM) is different from remote therapeutic monitoring. As previously mentioned, RPM and RTM differ because RTM focuses on non-physiological monitoring. On the other hand, RPM focuses on physiological data. Providers can choose from a growing list of FDA-cleared remote patient monitoring devices and software services.

Remote patient monitoring enables the monitoring of patient vital signs outside of conventional clinical settings, such as at home or in remote areas. This telehealth service allows patients to take measurements from their homes. Once the measurement is taken, the data is sent in real-time to providers to measure physiologic data such as heart rate, weight, oxygen saturation, pulse rate, glucose levels, and more.

 Over recent years, CMS created RPM billing codes for reimbursement for digital health, which has expanded Medicare reimbursement for remote patient monitoring. This is a separate category from RTM billing codes and services. These 5 RPM CPT codes are 99453, 99454, 99457, 99458, and 99091. 

RPM and RTM Billing: 2024 RPM Key Takeaways

What are the key takeaways for medical professionals regarding RTM and RPM billing for 2024? Although future modifications to remote patient monitoring CPT codes are expected, CMS did not add the Proposed Rule RPM G codes to the final rule. CMS further establishes rates and provides yearly guidance on requirements and utilization for remote monitoring services.

As a result, these are the 3 key takeaways for RPM in 2024:

• No new RPM CPT codes appear in the final rule for 2024.
• Medicare non-facility reimbursement rates were updated for 2024
• RPM providers will continue to use CPT codes 99453, 99454, 99457, 99458, and 99091.  

RPM 2024 CPT Code Reimbursement Rates

As of 2020, CMS adopted RPM CPT codes to pay for device setup, collection, interpretation, and processing of remote physiological data. This section explains exactly what the 5 RPM CPT codes cover in 2024, including the average reimbursement rate and requirements. These rounded numbers are based on non-facility national averages and vary by region. These are different from RTM billing codes.

99453

Just as RTM billing codes cover device setup, this code pays for device set-up and patient education on the use of equipment for vital sign monitoring such as blood pressure, pulse oximetry, blood glucose, respiratory flow rate, and weight. Only one clinician bills this one-time code after the initial 16 days of monitoring in a 30-day period. The average national payment rate for CPT 99453 is $19.65.

99454

Supplying the device for daily recording or programmed alert transmissions is billed under code 99454. It may be used more than once, given that the patient uses the device at least 16 days per month. One clinician can bill CPT 99454 in a 30-day period. The average national payment rate for CPT 99454 is $48.63.

99457

This payment is for the initial 20 minutes of treatment management. An unspecified portion of that 20 minutes must involve interactive remote communication with the patient. However, how interactions must be provided is not explicitly defined. However, we assume a video call, phone call, email, and text messaging would suffice. The average national payment rate for CPT 99457 is $48.14.

Moreover, CPT 99457 is billed “incident to” under general supervision. Medicare providers can contract third-party remote patient monitoring companies to assist with RPM services. Ultimately, healthcare organizations can manage more patients and generate more revenue without significantly impacting workflows. 

99458

In 2024, CPT 99458 encompasses each additional 20 minutes of RPM services, with a maximum of 60 minutes in a calendar month. Similar to CPT 99457, documentation of how the time is distributed is required. The average national payment rate for CPT 99458 is $38.64.

99091

CPT 99091 was new in 2022 but had more requirements than the preceding codes. In 2024, it covers a minimum of 30 minutes in a calendar month for the time it takes clinical staff to gather, interpret, and process data that a patient transmits. It also covers at least one communication, which occurs by phone or email, whereby medical management or monitor advising occurs. The average national payment rate for CPT 99091 is $52.71.

Understanding RPM and RTM Billing Codes

Remote therapeutic monitoring and remote patient monitoring are two distinct categories of remote monitoring services with specific CPT codes and billing requirements. A key difference between RTM and RPM is that RTM focuses on tracking non-physiological patient data like medication adherence, while RPM follows vital signs and physiological metrics. The 2024 Physician Fee Schedule Final Rule provides clarification and billing guidance for providers offering these services starting January 1, 2024.

Importantly, RPM and RTM billing codes cannot both be used to bill for the same patient in the same month – only one clinician can submit claims. Additionally, reimbursement rates differ across the codes. As remote monitoring continues growing in healthcare, having a firm grasp of the respective CPT codes, rules for utilization, and payment rates will ensure appropriate delivery and billing of RPM and RTM services.

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“This article was originally published by Foley & Lardner LLP [Centers for Medicare and Medicaid Services RPM Policies (natlawreview.com)] on [11/8/2023], and is reprinted with permission.”

On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized new policies related to remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services reimbursed under the Medicare program. 

The guidance published in the 2024 Physician Fee Schedule final rule(2024 Final Rule) addresses billing scenarios and requests for clarifications on the appropriate use of these remote monitoring codes. The 2024 Final Rule clarifies CMS’ position on how it interprets certain requirements for these services. CMS rejected some of the proposals contained in the 2024 Proposed Rule and built upon previous RPM and RTM guidance. 

Below are the key takeaways RPM and RTM providers must know about the 2024 Final Rule.

RPM and RTM Clarifications

RPM Can Only be Furnished to an “Established Patient”

In prior rulemaking, RPM services have been limited to “established patients.” Historically, in order to become an established patient for Medicare RPM purposes, a patient typically would undergo a new patient Evaluation and Management (E/M), or similar service, during which the billing practitioner collects relevant information about the patient and then establishes a treatment plan. During the Public Health Emergency (PHE), CMS waived the established patient requirement. When the PHE expired in May 2023, RPM services were once again limited to established patients. Those patients who received remote monitoring services during the PHE but who did not undergo an initial new patient exam will be deemed “established patients” under CMS’ recent rule clarification.

In sum, Medicare patients who received initial RPM services during the PHE will be considered established patients (i.e., patients who began receiving RPM services during the PHE will be “grandfathered” in). Those patients who receive initial RPM services after May 11, 2023 (the end of the PHE) will need to become an established patient before enrolling in a Medicare RPM services program.

RTM Does Not Contain an “Established Patient” Requirement

While RPM services require an established patient relationship prior to billing RPM codes, RTM services have no such express requirement (at least not yet). We highlighted this distinction in our prior coverage and encouraged stakeholders to submit comments and ask CMS to confirm whether or not the “established patient” requirement applies to both RPM and RTM, or just RPM.

CMS confirmed in the 2024 Final Rule, “RPM, not RTM, services require an established patient relationship after the end of the PHE.” Despite the lack of an express requirement, CMS expressed its belief that RTM services would be furnished to a patient only after a treatment plan has been established (and presumably after the billing practitioner conducted an initial interaction evaluation with the patient).

Under current RTM rules, the failure to conduct an initial patient evaluation and create an “established patient” relationship may not be a per se deviation of RTM billing requirements, but it remains possible that failing to complete this initial interaction and create a treatment plan could expose RTM practitioners to post-payment audits based on Medicare’s “reasonable and necessary” standard. CMS said it will clarify this policy in future rulemaking.

Practitioners Must Collect at Least 16 Days of Data Per 30-Day Period

In the 2024 Final Rule, CMS clarified which remote monitoring codes require at least 16 days of data collection in a 30-day period, and which codes have no such requirement. Prior CMS commentary indicated the RPM and RTM set-up and device codes (CPT codes 99453, 98976, 99454, 98977, and 98978) required at least 16 days of data collection. However, there was ambiguity as to whether or not the 16-day requirement applied to the four treatment management codes (CPT codes 99457, 99458, 98980, and 98981). We highlighted this ambiguity in our previous blog post and encouraged interested stakeholders to submit comments advocating for greater flexibility on the 16-day requirement.

In the 2024 Final Rule, CMS wrote:

We note that in the CY 2024 PFS proposed rule, we inadvertently listed all of the RTM codes (88 FR 53204) in our discussion of these services and had made a general statement about the applicability of the 16-day data collection requirement. We would like to offer clarification that the 16-day data collection requirement does not apply to CPT codes 99457, 99458, 98980, and 98981. These CPT codes are treatment management codes that account for time spent in a calendar month and do not require 16 days of data collection in a 30-day period.

This represents the first time CMS expressly stated in published guidance how the 16-day data collection requirement does not apply to the RPM and RTM treatment management codes (CPT codes 99457, 99458, 98980, and 98981).

Only One Practitioner Can Bill Medicare for RPM/RTM Services

In a given 30-day period, only one practitioner can bill RPM (CPT codes 99453 and 99454) or RTM (CPT codes 98976, 98977, 98980, and 98981), and only when at least 16 days of data has been collected on at least one medical device. “Even when multiple medical devices are provided to a patient,” CMS explained, “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.” Moreover, remotely-monitored monthly services should be billed only when reasonable and necessary, consistent with prior CMS guidance.

When reiterating that only one practitioner can bill these codes, CMS did not expressly list the two codes for RPM treatment management services (CPT codes 99457 and 99458), although CMS did list the two codes for RTM treatment management services. In future rulemaking, interested stakeholders should consider asking CMS to clarify whether or not multiple practitioners can bill CPT codes 99457 and 99458 for the same patient in the same 30-day period. Until then, while it arguably may not be a per se deviation of RPM billing requirements to have multiple practitioners simultaneously bill Medicare for the same patient, it remains possible that such billing could expose RPM practitioners to claim denials or post-payment audits based on Medicare’s “reasonable and necessary” standard.

Use of RPM/RTM with Other Services

Practitioners are permitted to bill Medicare for RPM or RTM (but not both) concurrently with the following care management services for the same patient so long as the time and effort is not counted twice: Chronic Care Management (CCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Chronic Pain Management (CPM). By allowing this concurrent billing, CMS intends to afford practitioners maximum flexibility when selecting the right combination of care management services for patients, while still guarding against fraud, waste, and abuse.

This restriction is not limited to Medicare. The 2023 CPT Codebook Guidance explains that CPT code 98980/98981 (RTM treatment management) cannot be reported in conjunction with CPT codes 99457/99458 (RPM treatment management).

Billing RPM or RTM During Global Surgery Periods

When a billing practitioner furnishes a procedure or surgery subject to a global billing period (where the practitioner receives a lump payment covering the post-surgical follow-up services within the global period), that practitioner cannot bill Medicare for RPM or RTM services provided to the patient during that global period. This is because the global billing payment received by the practitioner covers those post-surgical follow-up services during the period. This policy was clarified in the 2024 Final Rule.

However, the policy that prohibits RPM or RTM services being furnished during the global period only applies to billing practitioners who are receiving the global service payment. Practitioners, such as therapists, who are not receiving a global service payment because they did not furnish the global procedure, are permitted to furnish RPM or RTM services during a global period. Providing RTM or RPM services during the global period is permitted if the practitioner is not receiving global service payment because they did not furnish the global procedure. This means, for example, a doctor can perform surgery on a patient under global billing, and a physical therapist can enroll the patient in the therapist’s RTM program for post-surgery rehab and monitoring.

Correspondingly, CMS explained how, for a patient who already is receiving RPM or RTM services during a global period, a practitioner may furnish RPM or RTM services (but not both) to the patient, and Medicare will pay the practitioner separately for the RPM or RTM, so long as the remote monitoring services are unrelated to the diagnosis for which theglobal procedure is performed, and as long as the purpose of the remote monitoringaddresses an episode of care that is separate and distinct from the episode of care for theglobal procedure – meaning that the remote monitoring services address an underlyingcondition that is not linked to the global procedure or service.

FQHCs and RHCs May Receive Separate Reimbursement for RPM and RTM Services

Historically, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) were not authorized to separately bill for RPM and RTM services, and payment was made through an all-inclusive rate rather than separate reimbursement. Beginning January 1, 2024, FQHCs and RHCs may now separately bill Medicare for RPM and RTM. They do so using the general care management code (HCPCS code G0511) on an FQHC or RHC claim form. The RPM/RTM services must be medically reasonable and necessary, meet all the coding requirements, and cannot be duplicative of services already paid for under the general care management code for an episode of care in a given calendar month.

RHCs and FQHCs may bill HCPCS code G0511 multiple times in a calendar month, according to CMS’ commentary, provided all requirements are met and resource costs are not counted more than once. CMS will post the final 2024 payment rate for the general care management HCPCS code G0511 on the RHC and FQHC center websites (which can be accessed here and here).

Physical Therapists and Occupational Therapists can Bill RTM for Assistants Under General Supervision

Physical therapists (PTs) and occupational therapists (OTs) can provide and bill Medicare for RTM services. However, Medicare regulations for PTs and OTs in private practice (PTPPs and OTPPs) required all physical and occupational therapy services in that setting to be performed by, or under the direct supervisionof, the PT or OT. Requiring direct supervision levels renders it difficult for PTPPs and OTPPs to bill for RTM services performed by assistants (PTAs and OTAs) under their supervision.

Beginning January 1, 2024, Medicare will only require general supervision for PTPPs and OTPPs to bill for RTM services furnished by their PTAs and OTAs. This change is accomplished through the establishment of an RTM specific general supervision provision in 42 C.F.R. § 410.59(a)(3)(ii) and (c)(2) and 42 C.F.R. § 410.60(a)(3)(ii) and (c)(2). One caveat to this change: Medicare will continue to require PTPPs and OTPPs to directly supervise their employed PTs and OTs if the PT or OT being supervised is not individually enrolled in Medicare.

RPM is Not Included in the Definition of Primary Care Services for MSSP

In the Proposed Rule, CMS considered adding RPM CPT codes 99457 and 99458 to the definition of primary care services used for purposes of beneficiary assignment in the Medicare Shared Savings Program (MSSP). In the Final Rule, however, CMS chose not to add those codes.

Based on its commentary, CMS’ concern is that while RPM codes could be billed by primary care providers to support the overall management of a patient’s care, the codes can also be billed by specialists. Because only one treating practitioner can bill RPM for a given patient, if a specialist bills these codes to support management of a specific condition, the patient’s primary care provider would not be able to also bill RPM treatment management services for the patient. As a result, including the RPM codes in the definition of primary care services for purposes of assignment could inappropriately affect the determination of where a beneficiary received a plurality of their primary care services under MSSP rules.

Conclusion

The 2024 Final Rule reflects a continued maturation of RPM and RTM Medicare billing guidance. However, there continues to be some lack of clarity in the operation of RPM and RTM codes, some of which has been created by the iterative rulemaking process itself. Stakeholders should consider participating in future rulemaking in greater numbers to more quickly resolve some of the areas of uncertainty to allow these services to be better used to support increased quality and innovation in digital health models available to patients. 

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First, the bad news: The final 2024 Physician Fee Schedule rule rolled out by the U.S. Centers for Medicare & Medicaid Services contains virtually the same cuts to payment under Medicare Part B as were in the proposed rule. But this time around, there’s also good news: Many of the more positive elements in the proposed rule also remain, as does the possibility for future favorable shifts, particularly around PTA supervision. While final rule’s 3.4% reduction to the conversion factor shows the agency continuing down an unsustainable path that will require both short- and long-term congressional intervention, several of the provisions set to be put in place Jan. 1 are clear advocacy wins for APTA and its supporters.

Here’s an overview of the major elements of the final rule. (For additional insights, join us on Nov. 16 for a live webinar on the final rule. It’s free for APTA members and available at a significantly reduced rate for non-members.)

The conversion factor cuts are harmful, but they could’ve been worse, and KX modifier thresholds were adjusted.
The final rule includes another decrease in the conversion factor, one of the elements used in calculating final payment amounts for various codes. This time around, the conversion factor as initially reported by CMS is $32.7375, a 3.4% decrease from the $33.8872 conversion factor adopted in 2023. The impact of the cut is far-reaching, affecting more than 27 specialties including physical therapy.

While still damaging, the cut was less than the anticipated 4.2% drop. The reason, according to CMS, is that it reconsidered utilization estimates of a particular evaluation and management add-on code, which in turn allowed the agency to lessen the cuts to the conversion factor. CMS must make the reductions to the conversion factor to offset the evaluation and management increases in order to maintain budget neutrality.

Now that the final rule has been issued, the only possibility for relief from the cuts comes by way of Congress, which could step in with last-minute appropriations, as it did for the past three years.

APTA will be advocating for a similar short-term fix this year. At the same time, the association will continue its press for long-term solutions, pointing to the cuts as symptomatic of an outdated payment system. APTA, APTA Private Practice, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have presented Congress with a set of policy principles as a first step toward an overhaul.

Also in the final rule: CMS set the threshold for use of the KX modifier — the modifier indicating that a service meets the criteria for a payment ceiling exception — at $2,330 for PT and speech-language pathologist services combined, and $2,330 for occupational therapy services. The Medical review threshold remains at $3,000 through 2027.

The practice expense elements for 19 therapy codes could potentially increase.
In early 2023, APTA made the case to CMS that several codes frequently used by PTs are subject to a kind of double jeopardy that unfairly cut values. The association offered two arguments: First, that   codes including therapeutic exercises, neuromuscular reeducation, gait training, and therapeutic activities were undervalued by the AMA Relative Value Scale Update Committee, or AMA RUC, that sets payment rates typically adopted by CMS; and second, that these codes simultaneously were subject to reductions associated with the Multiple Procedure Payment Reduction system. APTA asserted that both devaluations are being made for the same ostensible reason — to account for a duplicative practice expense when multiple codes are used on the same day. APTA told CMS that discounting codes twice for the same rationale didn’t make sense.

CMS listened, and in the final rule directs the AMA RUC to re-review its earlier value recommendations — a provision unchanged from the proposed rule. The list of affected codes can be found on Page 96 of the final rule. The codes up for reconsideration have already been added to the AMA RUC’s January meeting agenda; APTA believes that the values of many of the codes will be increased.

New caregiver training codes are on the books.
In another win for APTA, CMS finalized the adoption of codes that would allow PTs, OTs, SLPs, and other providers to bill for providing training to caregivers when a patient with a functional deficit is not present. APTA created the codes, submitted them for AMA consideration, and argued for their valuation levels at the AMA RUC level.

The final rule includes a definition of caregiver that’s broader than CMS’ earlier definition, which had limited the term to relatives of the beneficiary. The new definition, strongly supported by APTA, expands “caregiver” to include “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation,” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

The codes, found on Page 285 of the final rule, will be considered “sometimes therapy” and thus not subject to the Multiple Procedure Payment Reduction system. Despite APTA’s advocacy otherwise, the codes won’t be eligible for use in association with telehealth.

CMS provided clarifications on telehealth coding and reporting remote therapeutic monitoring treatment management codes.
CMS followed through from the proposed rule and corrected its mistake that excluded PTs in institutional settings from participating in the telehealth extension that is in place through 2024. Under the final rule, these PTs can participate in telehealth in the same way as PTs in private practice settings — by using the same 95 modifier that they’ve been using since the beginning of the public health emergency. The CMS decision settles, for now, the issue of whether PTs would be required to use new Place of Service codes that CMS adopted. They aren’t.

Also in the final rule, CMS responded to a criticism from APTA that requiring 16 days of monitoring for codes 98980 and 98981 — treatment management codes that account for time spent in a calendar month — isn’t appropriate for these types of services. CMS agreed, and clarified that the 16-day collection requirement doesn’t apply to the two codes.

The rule features more positive movement on PTA supervision, including deeper consideration of general supervision in private practice settings, an extension of virtual supervision allowances, and relaxation of supervision associated with RTM.
The proposed rule included a request for comments on the possibility of moving away from direct supervision of PTAs and occupational therapy assistants in private practice — currently the only setting under Medicare in which 100% on-site supervision is required — in favor of general supervision. APTA made this topic a central feature of its comments to CMS on the proposed rule and urged members to do the same in their individual letters to the agency.

While the final rule doesn’t change the current requirement, it does include a lengthy discussion of the evidence APTA and other commenters provided, including reference to a report commissioned by a coalition of provider groups including APTA that found that a change to general supervision of PTAs in private practice settings could result Medicare savings of $271 million over 10 years. CMS offered its standard language on comment solicitations in the final rule, stating that “we will take these comments into consideration for possible future rulemaking” — but the sheer length of the discussion in the rule may be a good sign.

The final rule also follows through on a proposal to extend virtual supervision of PTAs and OTAs through the end of 2024, and finalizes a general supervision-only requirement for PTAs performing remote therapeutic monitoring regardless of setting.

PTs get their first-ever opportunity to participate in the MIPS Value Pathways Program by way of the first cost measure they’ll be able to report — and will begin MIPS reporting on interoperability.
The rule finalizes several proposed changes to the PT’s role in the CMS Quality Payment Program, or QPP, specifically within the Merit-based Incentive Payment System, or MIPS, and its MIPS Value Pathways program, or MVP.

First, the rule incorporates a new, APTA-recommended MVP based on musculoskeletal care, with a single — and also first-ever — cost measure PTs can use on low back pain. The rule also calls for APTA and other entities to submit existing measure recommendations through the MVP maintenance process, and to work with measure developers to create additional measures for inclusion in the MIPS measure inventory.

Second, CMS will no longer exempt physical therapy practices of 16 or more clinicians from the promoting interoperability category of MIPS, which will in turn require practices to have certified electronic health records technology in place for at least six months in 2024 (practices of 15 or fewer clinicians will still qualify for the exemption). Bottom line: All clinicians (except for clinical social workers), including PTs, will have their MIPS scoring weighted normally in the interoperability category in the 2024 performance year. The change wouldn’t apply to hospital-based clinicians and clinicians in small practices. APTA will issue extensive guidance on how to comply with the new QPP policies in the coming weeks.

Want to take a deeper dive into the 2024 fee schedule?  Join us on Nov. 16, 2023, for a special edition live webinar led by APTA staff: CMS 2024 Physician Fee Schedule Final Rule. The event, which offers CE credits, is free to APTA members and available to non-members at a significantly reduced rate. Register today and spread the word.

The post Final 2024 Physician Fee Schedule Reflects System’s Flaws; Includes Some Wins appeared first on mTelehealth.

Consolidated codes for reporting current COVID-19 immunizations, provisional codes for forthcoming monovalent vaccines, and codes for Respiratory Syncytial Virus (RSV) immunizations are among the features of the American Medical Association’s 2024 Current Procedural Terminology (CPT) code set unveiled today.

In all, the 2024 code set includes 230 additions, 49 deletions and 70 revisions among its 11,163 codes according to an AMA news release.

The 2024 version will also be the first to offer Spanish language descriptors for medical procedures and services. “Providing approximately 41 million Spanish speaking individuals in the United States with an easy-to-understand description of medical procedures and services can help build a more inclusive health care environment, where language is no longer a barrier and patients can actively engage in their own care,” Lori Prestesater, AMA senior vice president of health solutions said in the release.

To streamline the COVID-19 immunization reporting process, the 2024 code set consolidates more than 50 previous immunization reporting codes into 17 (91300-91317), and a new code (90480) for reporting the administration of any COVID-19 vaccine for any patient. The latter replaces all previously approved specific vaccine administration codes.

In addition, it includes provisional codes (91318-91322) for monovalent Moderna and Pfizer COVID-19 vaccines for when they are approved by the U.S. Food and Drug Administration.

The 2024 code set contains five new codes (90380, 90381, 90683, 90679 and 90678) developed in response to product-specific RSV immunizations. The codes will enable better tracking, reporting and analysis for planning and allocation purposes, the AMA said.

Responding to requests from the Centers for Medicare and Medicaid Services, some evaluation and management (E/M) reporting codes have been revised for greater clarification. The revisions include:

• Removing time ranges from office or other outpatient visit codes (99202-99205, 99212-99215) and aligning the format with other E/M codes,
• Defining the “substantive portion” of a split/shared E/M visit in which a physician and a non-physician practitioner work jointly to furnish all the work related to the visit, and
• Instructions for reporting hospital inpatient or observation care services and admission and discharge services for the use of codes 99234-99236 when the patient stay crosses over two calendar dates.

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CMS 2024 Proposed Rule Policy Updates 

On July 13, 2023, the Center for Medicare and Medicaid Services (CMS) released the CMS 2024 Proposed Rule and Medicare Physician Fee Schedule, including possible Medicare payments under the Physician Fee Schedule and other Medicare Part B issues policy updates.

While the CMS 2024 proposed rule contained no new CPT codes, it addressed ambiguities in telehealth, remote therapeutic monitoring (RTM), and remote patient monitoring (RPM) regulations. This article explores key takeaways from Medicare’s proposed changes affecting telehealth, remote patient monitoring, and remote therapeutic monitoring.

Telehealth CMS 2024 Proposed Rule Takeaways

The CMS 2024 proposed rule has proposed extending several telehealth provisions through the end of 2024. This includes reimbursement at non-facility rates for specific telehealth services provided in a patient’s home. It also adds physical therapists, occupational therapists, speech-language pathologists, and audiologists to the list of distant site practitioners. The proposed rule also proposes a new process for adding, removing, or otherwise changing Medicare Telehealth Service list codes. This would create differential payment based on the place of service.

Remote Patient Monitoring CMS 2024 Proposed Rule Takeaways

RPM and RTM are available only to established patients, but those who received remote monitoring during the PHE are now considered established. Practitioners can choose remote patient monitoring or therapeutic monitoring alongside certain care management services without double-counting time.

Same Patient Billing for RPM and RTM 

CMS 2024 proposed rule aims to clarify RPM and RTM billing for patients with multiple devices. CMS states that both services cannot be billed together, and time cannot be double-counted by billing concurrently. Only one practitioner can bill reasonable and necessary services associated with all devices, once per patient every 30 days and only after at least 16 days of monitoring data. 

16-Day Requirement

CMS still requires monitoring over 16 days within 30 days, causing concerns for patients who may benefit from fewer days of monitoring.

Payment During Global Surgery Periods

CMS proposes to clarify rules for using remote monitoring during global periods for surgery. Patients can receive either RPM or RTM services, but not both simultaneously. The practitioner will receive separate payments for one service only and the global service payment. They must meet all requirements for the global service and any other service during the global period.

Payment for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

CMS is considering allowing FQHCs and RHCs to bill separately for RPM and RTM services.

RPM and Primary Care Services under Medicare Shared Savings Program (MSSP)

CPT codes 99457 and 99548 may be classified as primary care services for MSSP beneficiary assignments.

Additional CMS 2024 Proposed Rule Takeaways

The following section covers key takeaways for additional virtual care management services. 

For the calendar year 2024, physician fees will reduce by 1.25%. Accordingly, the conversion factor will decrease by $1.14 (or 3.34%), dropping from $33.89 in 2023 to $32.75 in 2024.

Health Equity-Focused Coding and Payment Proposals

The CMS 2024 proposed rule outlines several essential services to assist underserved communities. These proposals include caregiver training programs, separate coding and payment for community health integration services, payment for principal illness navigation services, and coding and payment for social determinants of health risk assessments.

Promoting Whole-Person Care

To further improve care quality, CMS has implemented changes to the Medicare Shared Savings Program (MSSP) that encourage whole-person care. The proposed changes include revisions to Accountable Care Organization (ACO) assignment and financial benchmarking methodology.

Providing Feedback on the 2024 Proposed Rule

Stakeholder comments are welcomed on the CMS 2024 proposed rule during the 60-day comment period, which will close on Sept. 11, 2023. In early November 2023, CMS will publish the 2024 Final Rule to solidify the path forward for Medicare beneficiaries and healthcare providers.

The post CMS 2024 Proposed Rule Key Takeaways for RPM, RTM & Telehealth appeared first on mTelehealth.

§ 411.15 Particular services excluded from coverage.

Link to an amendment published at 88 FR 53345, Aug. 7, 2023.

The following services are excluded from coverage:

(a) Routine physical checkups such as:

(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in § 410.64 of this chapter, or annual wellness visits providing personalized prevention plan services.

(2) Examinations required by insurance companies, business establishments, government agencies, or other third parties.

(b) Low vision aid exclusion—(1) Scope. The scope of the eyeglass exclusion encompasses all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.

(2) Exceptions.

(i) Post-surgical prosthetic lenses customarily used during convalescence for eye surgery in which the lens of the eye was removed (for example, cataract surgery).

(ii) Prosthetic intraocular lenses and one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.

(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.

(c) Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only and procedures performed in the course of any eye examination to determine the refractive state of the eyes, without regard to the reason for the performance of the refractive procedures. Refractive procedures are excluded even when performed in connection with otherwise covered diagnosis or treatment of illness or injury.

(d) Hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids.

(1) Scope. The scope of the hearing aid exclusion encompasses all types of air conduction hearing aids that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound and bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.

(2) Devices not subject to the hearing aid exclusion. Paragraph (d)(1) of this section shall not apply to the following devices that produce the perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve:

(i) Osseointegrated implants in the skull bone that provide mechanical energy to the cochlea via a mechanical transducer, or

(ii) Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.

(e) Immunizations, except for—

(1) Vaccinations or inoculations directly related to the treatment of an injury or direct exposure such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenom sera, or immune globulin;

(2) Pneumococcal vaccinations that are reasonable and necessary for the prevention of illness;

(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in § 410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;

(4) Influenza vaccinations that are reasonable and necessary for the prevention of illness; and

(5) COVID–19 vaccinations that are reasonable and necessary for the prevention of illness.

(f) Orthopedic shoes or other supportive devices for the feet, except when shoes are integral parts of leg braces.

(g) Custodial care, except as necessary for the palliation or management of terminal illness, as provided in part 418 of this chapter. (Custodial care is any care that does not meet the requirements for coverage as SNF care as set forth in §§ 409.31 through 409.35 of this chapter.)

(h) Cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.

(i) Dental services—(1) Basic rule. Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.

(2) Exception. Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of—

(i) The individual’s underlying medical condition and clinical status; or

(ii) The severity of the dental procedures. 577

577 Before July 1981, inpatient hospital care in connection with dental procedures was covered only when required by the patient‘s underlying medical condition and clinical status.

(3) Inapplicability.

(i) Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for services furnished in the inpatient or outpatient setting. Such services include, but are not limited to:

(A) Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant, cardiac valve replacement, or valvuloplasty procedure.

(B) The reconstruction of a dental ridge performed as a result of and at the same time as the surgical removal of a tumor.

(C) The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints.

(D) The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

(ii) Ancillary services and supplies furnished incident to covered dental services are not excluded, and Medicare payment may be made under Part A or Part B, as applicable, whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.

(j) Personal comfort services, except as necessary for the palliation or management of terminal illness as provided in part 418 of this chapter. The use of a television set or a telephone are examples of personal comfort services.

(k) Any services that are not reasonable and necessary for one of the following purposes:

(1) For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

(2) In the case of hospice services, for the palliation or management of terminal illness, as provided in part 418 of this chapter.

(3) In the case of pneumococcal vaccine for the prevention of illness.

(4) In the case of the patient outcome assessment program established under section 1875(c) of the Act, for carrying out the purpose of that section.

(5) In the case of hepatitis B vaccine, for the prevention of illness for those individuals at high or intermediate risk of contracting hepatitis B. (Section 410.63(a) of this chapter sets forth criteria for identifying those individuals.)

(6) In the case of screening mammography, for the purpose of early detection of breast cancer subject to the conditions and limitations specified in § 410.34 of this chapter.

(7) In the case of colorectal cancer screening tests, for the purpose of early detection of colorectal cancer subject to the conditions and limitations specified in § 410.37 of this chapter.

(8) In the case of screening pelvic examinations, for the purpose of early detection of cervical or vaginal cancer subject to the conditions and limitations specified in § 410.56 of this chapter.

(9) In the case of prostate cancer screening tests, for the purpose of early detection of prostate cancer, subject to the conditions and limitations specified in § 410.39 of this chapter.

(10) In the case of screening exams for glaucoma, for the purpose of early detection of glaucoma, subject to the conditions and limitations specified in § 410.23 of this chapter.

(11) In the case of initial preventive physical examinations, with the goal of health promotion and disease prevention, subject to the conditions and limitations specified in § 410.16 of this chapter.

(12) In the case of ultrasound screening for abdominal aortic aneurysms, with the goal of early detection of abdominal aortic aneurysms, subject to the conditions and limitation specified in § 410.19 of this chapter.

(13) In the case of cardiovascular disease screening tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for that disease, subject to the conditions specified in § 410.17 of this chapter.

(14) In the case of diabetes screening tests furnished to an individual at risk for diabetes for the purpose of the early detection of that disease, subject to the conditions specified in § 410.18 of this chapter.

(15) In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter.

(16) In the case of an annual wellness visit providing a personalized prevention plan, subject to the conditions and limitations specified in § 410.15 of this subpart.

(l) Foot care—(1) Basic rule. Except as provided in paragraph (l)(2) of this section, any services furnished in connection with the following:

(i) Routine foot care, such as the cutting or removal of corns, or calluses, the trimming of nails, routine hygienic care (preventive maintenance care ordinarily within the realm of self care), and any service performed in the absence of localized illness, injury, or symptoms involving the feet.

(ii) The evaluation or treatment of subluxations of the feet regardless of underlying pathology. (Subluxations are structural misalignments of the joints, other than fractures or complete dislocations, that require treatment only by nonsurgical methods.

(iii) The evaluation or treatment of flattened arches (including the prescription of supportive devices) regardless of the underlying pathology.

(2) Exceptions.

(i) Treatment of warts is not excluded.

(ii) Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment.

(iii) The services listed in paragraph (l)(1) of this section are not excluded if they are furnished—

(A) As an incident to, at the same time as, or as a necessary integral part of a primary covered procedure performed on the foot; or

(B) As initial diagnostic services (regardless of the resulting diagnosis) in connection with a specific symptom or complaint that might arise from a condition whose treatment would be covered.

(m) Services to hospital patients—(1) Basic rule. Except as provided in paragraph (m)(3) of this section, any service furnished to an inpatient of a hospital or to a hospital outpatient (as defined in § 410.2 of this chapter) during an encounter (as defined in § 410.2 of this chapter) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the hospital‘s patients. As used in this paragraph (m)(1), the term “hospital” includes a CAH.

(2) Scope of exclusion. Services subject to exclusion from coverage under the provisions of this paragraph (m) include, but are not limited to, clinical laboratory services; pacemakers and other prostheses and prosthetic devices (other than dental) that replace all or part of an internal body organ (for example, intraocular lenses); artificial limbs, knees, and hips; equipment and supplies covered under the prosthetic device benefits; and services incident to a physician service.

(3) Exceptions. The following services are not excluded from coverage:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a reasonable charge or fee schedule basis.

(ii) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act, that are furnished after December 31, 1990.

(iii) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.

(iv) Certified nurse-midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, 1990.

(v) Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, 1990.

(vi) Services of an anesthetist, as defined in § 410.69 of this chapter.

(n) Certain services of an assistant-at-surgery.

(1) Services of an assistant-at-surgery in a cataract operation (including subsequent insertion of an intraocular lens) unless, before the surgery is performed, the appropriate QIO or a carrier has approved the use of such an assistant in the surgical procedure based on the existence of a complicating medical condition.

(2) Services on an assistant-at-surgery in a surgical procedure (or class of surgical procedures) for which assistants-at-surgery on average are used in fewer than 5 percent of such procedures nationally.

(o) Experimental or investigational devices, except for certain devices.

(1) Categorized by the FDA as a Category B (Nonexperimental/investigational) device as defined in § 405.201(b) of the chapter; and

(2) Furnished in accordance with the coverage requirements in § 405.211(b).

(p) Services furnished to SNF residents—(1) Basic rule. Except as provided in paragraph (p)(2) of this section, any service furnished to a resident of an SNF during a covered Part A stay by an entity other than the SNF, unless the SNF has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the SNF‘s residents. Services subject to exclusion under this paragraph include, but are not limited to—

(i) Any physical, occupational, or speech-language therapy services, regardless of whether the services are furnished by (or under the supervision of) a physician or other health care professional, and regardless of whether the resident who receives the services is in a covered Part A stay; and

(ii) Services furnished as an incident to the professional services of a physician or other health care professional specified in paragraph (p)(2) of this section.

(2) Exceptions. The following services are not excluded from coverage, provided that the claim for payment includes the SNF‘s Medicare provider number in accordance with § 424.32(a)(5) of this chapter:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a fee schedule basis.

(ii) Services performed under a physician‘s supervision by a physician assistant who meets the applicable definition in section 1861(aa)(5) of the Act.

(iii) Services performed by a nurse practitioner or clinical nurse specialist who meets the applicable definition in section 1861(aa)(5) of the Act and is working in collaboration (as defined in section 1861(aa)(6) of the Act) with a physician.

(iv) Services performed by a certified nurse-midwife, as defined in section 1861(gg) of the Act.

(v) Services performed by a qualified psychologist, as defined in section 1861(ii) of the Act.

(vi) Services performed by a certified registered nurse anesthetist, as defined in section 1861(bb) of the Act.

(vii) Dialysis services and supplies, as defined in section 1861(s)(2)(F) of the Act, and those ambulance services that are furnished in conjunction with them.

(viii) Erythropoietin (EPO) for dialysis patients, as defined in section 1861(s)(2)(O) of the Act.

(ix) Hospice care, as defined in section 1861(dd) of the Act.

(x) An ambulance trip that initially conveys an individual to the SNF to be admitted as a resident, or that conveys an individual from the SNF in connection with one of the circumstances specified in paragraphs (p)(3)(i) through (p)(3)(iv) of this section as ending the individual’s status as an SNF resident.

(xi) The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those electrocardiogram test services furnished during 1998.

(xii) Services described in subparagraphs (p)(2)(i) through (vi) of this section when furnished via telehealth under section 1834(m)(4)(C)(ii)(VII) of the Act.

(xiii) Those chemotherapy items identified, as of July 1, 1999, by HCPCS codes J9000–J9020, J9040–J9151, J9170–J9185, J9200–J9201, J9206–J9208, J9211, J9230–J9245, and J9265–J9600, and as of January 1, 2004, by HCPCS codes A9522, A9523, A9533, and A9534 (as subsequently modified by CMS), and any additional chemotherapy items identified by CMS.

(xiv) Those chemotherapy administration services identified, as of July 1, 1999, by HCPCS codes 36260–36262, 36489, 36530–36535, 36640, 36823, and 96405–96542 (as subsequently modified by CMS), and any additional chemotherapy administration services identified by CMS.

(xv) Those radioisotope services identified, as of July 1, 1999, by HCPCS codes 79030–79440 (as subsequently modified by CMS), and any additional radioisotope services identified by CMS.

(xvi) Those customized prosthetic devices (including artificial limbs and their components) identified, as of July 1, 1999, by HCPCS codes L5050–L5340, L5500–L5611, L5613–L5986, L5988, L6050–L6370, L6400–6880, L6920–L7274, and L7362–L7366 (as subsequently modified by CMS) and any additional customized prosthetic devices identified by CMS, which are delivered for a resident’s use during a stay in the SNF and intended to be used by the resident after discharge from the SNF.

(xvii) Those blood clotting factors indicated for the treatment of patients with hemophilia and other bleeding disorders identified, as of July 1, 2020, by HCPCS codes J7170, J7175, J7177–J7183, J7185–J7190, J7192–J7195, J7198–J7203, J7205, and J7207–J7211 (as subsequently modified by CMS) and items and services related to the furnishing of such factors, and any additional blood clotting factors identified by CMS and items and services related to the furnishing of such factors.

(xviii) Those RHC and FQHC services that are described in § 405.2411(b)(2) of this chapter.

(3) SNF resident defined. For purposes of this paragraph, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF for the duration of the beneficiary‘s covered Part A stay. In addition, for purposes of the services described in paragraph (p)(1)(i) of this section, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF regardless of whether the beneficiary is in a covered Part A stay. Whenever the beneficiary leaves the facility, the beneficiary‘s status as an SNF resident for purposes of this paragraph (along with the SNF‘s responsibility to furnish or make arrangements for the services described in paragraph (p)(1) of this section) ends when one of the following events occurs—

(i) The beneficiary is admitted as an inpatient to a Medicare-participating hospital or CAH, or as a resident to another SNF;

(ii) The beneficiary receives services from a Medicare-participating home health agency under a plan of care;

(iii) The beneficiary receives outpatient services from a Medicare-participating hospital or CAH (but only for those services that CMS designates as being beyond the general scope of SNF comprehensive care plans, as required under § 483.21(b) of this chapter); or

(iv) The beneficiary is formally discharged (or otherwise departs) from the SNF, unless the beneficiary is readmitted (or returns) to that or another SNF before the following midnight.

(q) Assisted suicide. Any health care service used for the purpose of causing, or assisting to cause, the death of any individual. This does not pertain to the withholding or withdrawing of medical treatment or care, nutrition or hydration or to the provision of a service for the purpose of alleviating pain or discomfort, even if the use may increase the risk of death, so long as the service is not furnished for the specific purpose of causing death.

(r) A home health service (including medical supplies described in section 1861(m)(5) of the Act, but excluding durable medical equipment to the extent provided for in such section) as defined in section 1861(m) of the Act furnished to an individual who is under a plan of care of an HHA, unless that HHA has submitted a claim for payment for such services.

(s) Unless § 414.404(d) or § 414.408(e)(2) of this subchapter applies, Medicare does not make payment if an item or service that is included in a competitive bidding program (as described in part 414, subpart F of this subchapter) is furnished by a supplier other than a contract supplier (as defined in § 414.402 of this subchapter).

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2023: New Federal Developments

There were no new federal developments in the last month.

2023: New State-Level Developments

Payment Parity: Permanent State Laws and Statutes

Payment Parity requires that health care providers are reimbursed the same amount for telehealth visits as in-person visits. During the COVID-19 pandemic, many states implemented temporary payment parity through the end of the public health emergency. Now, many states are implementing payment parity on a permanent basis. As portrayed in Figure 1, as of July 2023, 21 states have implemented policies requiring payment parity, 8 states have payment parity in place with caveats, and 21 states have no payment parity.

_{Figure 1. Map of States With Laws Requiring Insurers to Implement Payment Parity (as of July 2023)}

2023: Federal Developments More than One Month Old

For a list of Federal Developments from 2020-2022, please see here.

Executive Branch Activity

Legislative Activity

Other Information of Interest

For the full list of other activities and updates from 2020-2022, please see here.

In February 2023, the American Medical Association CPT Editorial Panel added 17 new CPT codes that can be used to report telemedicine E/M office visits. The Panel also removed three codes for billing telephonic E/M office visits. These changes will be effective January 2025.

The post Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 appeared first on mTelehealth.