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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In November 2023, CMS issued final rules for the 2024 Medicare Physician Fee Schedule (MPFS) and the 2024 Medicare Outpatient Prospective Payment System (OPPS). Both of these rules contained finalized policy proposals that will impact rural health clinics (RHCs) beginning in January 2024:

• Telehealth Flexibilities
• Medicare Coverage of Marriage and Family Therapists and Mental Health Counselor Services
• Intensive Outpatient Program (IOP) Services Billable in RHC Under Special Payment Rule
• Expansion of RHC Care Management Services
• Definition Change to Nurse Practitioner

Telehealth Flexibilities

CMS has officially extended some telehealth flexibilities that were allowed during the public health emergency (PHE) to continue through December 31, 2024. Specifically, CMS finalized the following:

• RHCs may be reimbursed for telehealth services utilizing CPT code G2025
• Removed the originating and geographic site requirements, which allows patients to be located in any location during the telehealth visit. This would include the patient’s home. It should be noted that telehealth services are to be provided during the RHC’s operating hours
• Delayed the in-person requirement for mental health visits performed via telehealth
• Extended audio-only coverage allowance for telehealth services
• Expanded the list of telehealth distant site providers to include Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs)

New Billable RHC Provider Types

MFTs and MHCs have now been officially added as qualified RHC provider types. An MHC is an individual who:

• “(A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a mental health counselor, clinical professional counselor, or professional counselor under the State law of the State in which such individual furnishes the services described in paragraph (3);
• (B) is licensed or certified as a mental health counselor, clinical professional counselor, or professional counselor by the State in which the services are furnished;
• (C) after obtaining such a degree has performed at least two years of clinical supervised experience in mental health counseling; and
• (D) meets such other requirements as specified by the Secretary.”

Effective January 1, 2024, MFTs and MHCs will be able to generate Medicare encounters and be reimbursed for those services at the RHC’s all-inclusive rate (AIR). MFTs and MHCs also have the ability to meet the requirement that a provider must be available to provide care to patients at all times the clinic is open.

Intensive Outpatient Program (IOP) Services

IOP services are outpatient mental health services that are designed for patients who require more complex mental health care than would be able to be accomplished during a typical office visit, but not so severe that an inpatient mental service would be required. These services are intended for patients with acute mental illnesses such as depression and substance abuse disorders who require a higher level of care. In its proposal, CMS specified the services eligible to be provided and reimbursed under an IOP may include:

• Individual and group therapy with physicians, psychologists, and other mental health professionals as available under state law
• Occupational therapy
• Furnishing of drugs and biologicals for therapeutic purposes that are not self-administered
• Family counseling (as part of treatment of the patient’s condition)
• Patient training and education
• Individualized activity therapies
• Diagnostic services
• Other related services for diagnosis and active treatment intended to improve or maintain the patient’s condition and function

To quality a patient for IOP services, a physician is required to certify that a patient needs behavioral health services for at least nine, but no more than 19 hours per week. That certification must be completed by a physician at least once every other month for the patient to continue to qualify for services and the plan of care must demonstrate that the patient:

• Requires at least nine hours of therapeutic services per week
• Is likely to benefit from coordinated services rather than individual sessions of outpatient treatment
• Does not need 24-hour care
• Has a support system outside of the IOP
• Has received a mental health diagnosis
• Is not a danger to themselves or others
• Has the cognitive and emotional ability to tolerate the IOP

IOP services will not be reimbursed at the RHC’s AIR, but rather under a special rule that would allow for a flat payment of approximately $280 per day. RHCs will be allowed to perform up to three services per day and to qualify for the special payment, at least one of the three services must be from Table 44 Proposed Partial Hospitalization and Intensive Outpatient Primary Services found on page 367 of the HOPPS Proposed Rule.

Because IOPs are a new service for RHCs, there is an expectation of future rulemaking outlining how services may be provided and reimbursed.

Expansion of RHC Care Management Services

Historically, RHCs have only been allowed to bill and be reimbursed for Care Management Services, including Remote Patient Monitoring, Remote Therapeutic Monitoring, or using CPT code G0511 or G0512 once per month per beneficiary. Under the new final rule, RHCs may now bill G0511 multiple times per month as long as the services rendered are “medically reasonable and necessary, meet all requirements, and not be duplicative of services paid to RHCs and FQHCs under the general care management code for an episode of care in a given calendar month.” In addition, CMS has finalized the establishment of new care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN), which also will be billed to Medicare using the G0511 code and those services will be reimbursed as long as a qualified provider performs the service.

Definition Change to Nurse Practitioner

CMS has changed the definition of a nurse practitioner to state that an individual must “be certified as a primary care nurse practitioner at the time of provision of services by a recognized national certifying body that has established standards for nurse practitioners and possesses a master’s degree in nursing or a Doctor of Nursing Practice (DNP) doctoral degree.” This change allows individuals certified by additional certifying boards, including the American Academy of Nurse Practitioners Certification Board, American Nurses Credentialing Center Certification Program, Pediatric Nursing Certification Board, and the National Certification Corporation, to now meet the definition of a nurse practitioner as long as the other requirements are met.

These changes may result in significant operational, revenue cycle, and regulatory reimbursement impacts for RHCs beginning in January 2024. If you have any questions about the new requirements or would like assistance in evaluating the organization’s readiness and potential impact, please reach out to a professional at FORVIS.

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On November 2, 2023, in the 2024 final rule for the physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) finalized crucial policies impacting remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services reimbursed under the Medicare program. This article breaks down the key takeaways of the Medicare final rule 2024 to guide companies through the changes and clarifications.

Medicare Final Rule 2024: RPM Exclusive to Established Patients

The Medicare final rule 2024 emphasizes that RPM services can only be furnished to “established patients.” This distinction, reinstated after the Public Health Emergency (PHE), requires patients who started RPM services during the PHE to become “established patients.” Those initiating RPM services after May 11, 2023, must undergo an initial evaluation to qualify.

This re-establishment of the “established patient” requirement aims to maintain a structured approach to RPM services, ensuring a foundation of familiarity with the patient’s health history and treatment plan.

RTM’s Unique Position

In contrast, RTM services offer flexibility and do not mandate an “established patient” requirement. While an initial interaction evaluation is advisable, the Medicare final rule 2024 clarifies that an established patient relationship is not expressly required for RTM services, with potential future rulemaking to address nuances.

This flexibility in RTM requirements allows practitioners to adapt their approach based on the unique needs of patients, potentially streamlining the onboarding process for remote therapeutic monitoring.

Medicare Final Rule 2024 Billing for RPM and RTM 

In the Medicare final rule 2024, CMS clarified that certain remote monitoring codes necessitate at least 16 days of data collection in 30 days. Treatment management codes (99457, 99458, 98980, and 98981) do not adhere to the 16-day requirement, offering practitioners greater flexibility.

This clarification on data collection requirements ensures practitioners understand the expectations for different remote monitoring codes. It also addresses concerns raised during the rulemaking process about the potential burden of a uniform 16-day requirement across all codes.

In a given 30-day period, only one practitioner can bill RPM/RTM services for a patient, even with multiple medical devices. This clarity ensures streamlined billing processes while aligning with CMS’s emphasis on reasonable and necessary services.

In the Medicare final rule 2024, the emphasis on singular practitioner billing aims to avoid confusion and potential overlapping claims, ensuring that one healthcare professional coordinates each patient’s remote monitoring services.

Billing RTM for Assistants Under General Supervision

Physical therapists (PTs) and occupational therapists (OTs) can now bill Medicare for RTM services according to the Medicare final rule 2024. This includes those provided by their assistants (PTAs and OTAs), with the requirement of general supervision. The change facilitates broader access to RTM services within private practice settings.

These expanded billing capabilities for PTs and OTs underscore the importance of incorporating a diverse range of healthcare professionals in the delivery of remote therapeutic monitoring. It recognizes the collaborative nature of healthcare and the contributions of various team members.

Concurrent Billing with Care Management Services

According to the Medicare final rule 2024, practitioners can bill Medicare for RPM or RTM concurrently with certain care management services, avoiding double counting of time and effort. This strategic approach allows practitioners to tailor patient care management services without compromising compliance.

The ability to concurrently bill for remote monitoring and other care management services reflects CMS’s commitment to providing comprehensive and coordinated healthcare. It encourages practitioners to leverage a combination of services to meet the diverse needs of patients.

Global Surgery Period in the Medicare Final Rule 2024

Billing practitioners cannot bill Medicare for RPM or RTM services during global surgery periods. However, practitioners not receiving global service payments, such as therapists, can provide these services during the global period, ensuring flexibility in patient care.

This distinction in billing practices during global surgery periods aims to balance the financial considerations for practitioners while focusing on patient care continuity. It encourages healthcare providers to adapt their billing strategies based on their specific patient treatment roles.

Separate Reimbursement: FQHCs and RHCs

Starting January 1, 2024, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can separately bill Medicare for RPM and RTM services, departing from the previous all-inclusive rate model. This change aims to enhance reimbursement and align with coding requirements.

The shift towards separate reimbursement for FQHCs and RHCs reflects a recognition of the unique challenges and services provided by these healthcare entities. It offers financial flexibility and acknowledges its role in delivering remote monitoring services to Medicare beneficiaries.

RPM Exclusion from MSSP Primary Care Services

While CMS considered including RPM CPT codes in the Medicare final rule 2024, the definition of primary care services for the Medicare Shared Savings Program (MSSP) ultimately chose not to. The concern lies in potential conflicts when specialists also bill RPM codes, affecting the assignment of primary care services under MSSP rules.

This decision reflects CMS’s commitment to maintaining the integrity of primary care services within the MSSP framework. By excluding RPM codes from the definition, CMS aims to prevent potential disruptions in assigning primary care services and ensure accurate representation in the program.

Understanding the Medicare Final Rule 2024

The Medicare final rule 2024 marks a milestone in the evolution of RPM and RTM Medicare billing. Despite increased clarity, some operational uncertainties persist, emphasizing the need for stakeholder engagement in future rulemaking to enhance the utilization of these services in advancing digital health models for patients.

We hope you have found these key takeaways helpful in further understanding the nuances within the Medicare Final Rule 2024. As healthcare providers navigate the evolving landscape of remote patient monitoring and therapeutic services, staying informed and actively participating in future rulemaking processes will be essential for optimizing patient care and compliance with CMS guidelines.

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In certain circumstances, the Secretary of the Department of Health and Human Services (HHS) using section 1135 of the Social Security Act (SSA) can temporarily modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements, called 1135 waivers.  There are different kinds of 1135 waivers, including Medicare blanket waivers.  When there’s an emergency, sections 1135 or 1812(f) of the SSA allow us to issue blanket waivers to help beneficiaries access care.  When a blanket waiver is issued, providers don’t have to apply for an individual 1135 waiver.  When there’s an emergency, we can also offer health care providers other flexibilities to make sure Americans continue to have access to the health care they need.

Update regarding intent to end the national emergency and public health emergency declarations and extensions by way of the Consolidated Appropriations Act (CAA) for Fiscal Year 2023

Update: On Thursday, December 29, 2022, President Biden signed into law H.R. 2716, the Consolidated Appropriations Act (CAA) for Fiscal Year 2023. This legislation provides more than $1.7 trillion to fund various aspects of the federal government, including an extension of the major telehealth waivers and the Acute Hospital Care at Home (AHCaH) individual waiver that were initiated during the federal public health emergency (PHE).

Additionally, on January 30, 2023, the Biden Administration announced its intent to end the national emergency and public health emergency declarations on May 11, 2023, related to the COVID-19 pandemic.

CMS is committed to updating supporting resources and providing updates as soon as possible. Please continue to use the provider-specific fact sheets for information about COVID-19 Public Health Emergency (PHE) waivers and flexibilities.

Waivers & flexibilities for health care providers

Apply for an 1135 waiver or submit a public health emergency (PHE)-related inquiry

• Get a quick-start guide to learn how to submit an 1135 General  waiver (PDF), an 1135 Medicaid waiver (PDF), or a PHE inquiry (PDF)

• Watch our YouTube training videos:
  • 1135 Medicaid Waiver/Flexibility Requests
  • 1135 General Waiver/Flexibility Requests
  • PHE-related Inquiry Requests
• Report technical issues by email (Note “Waiver/Flexibility” in the subject line)

Learn how we’re easing burden and helping providers care for Americans by offering new waivers and flexibilities:

Read our provider-specific fact sheets for information about COVID-19 Public Health Emergency (PHE) waivers and flexibilities. These fact sheets include information about which waivers and flexibilities have already been terminated, have been made permanent, or will end at the end of the PHE.

• Physicians and Other Clinicians (PDF)
• Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs (PDF)
• Teaching Hospitals, Teaching Physicians and Medical Residents  (PDF)
• Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities)  (PDF)
• Home Health Agencies   (PDF)
• Hospice (PDF)
• Inpatient Rehabilitation Facilities  (PDF)
• Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals (PDF)
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)  (PDF)
• Laboratories (PDF)
• Medicare Shared Savings Program (PDF)
• Durable Medical Equipment, Prosthetics, Orthotics and Supplies (PDF)
• Medicare Advantage and Part D Plans (PDF)
• Ambulances (PDF)
• End Stage Renal Disease (ESRD) Facilities (PDF)
• Participants in the Medicare Diabetes Prevention Program (PDF)
• Intermediate Care Facility for Individuals with Intellectual Disabilities (PDF)

• Waiver for Medicare Ground Ambulance Services Treatment in Place (PDF) (5/5/21)
• COVID-19 Emergency Declaration Blanket Waivers & Flexibilities for Health Care Providers (PDF) UPDATED (10/13/22)
• Blanket waivers of Section 1877(g) of the Social Security Act (3/30/20)
• Medicare and Medicaid IFC: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-9912 IFC) (PDF) (10/28/20)
  • CMS-9912 Interim Final Rule with Comment Factsheet on Updated Policy for Maintaining Medicaid Enrollment during the Public Health Emergency for COVID-19 (10/28/20)
• Medicare and Medicaid IFC: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-3401 IFC) (PDF) (8/25/20)
  • Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool (8/26/20)
  • Interim Final Rule (IFC), CMS-3401-IFC, Updating Requirements for Reporting of SARS-CoV-2 Test Results by (CLIA) of 1988 Laboratories, and Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (8/26/20)
• Medicare and Medicaid IFC: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-5531 IFC) (PDF) (4/30/20)
  • IFC Federal Register Announcement (5/4/20)
  • PRA Disclosure Statement (PDF) (5/21/20)
• Acute Hospital Care At Home waiver request (11/25/20)
• List of Hospital Outpatient Services and List of Partial Hospitalization Program Services Accompanying the 4/30/2020 IFC (ZIP) (4/30/20)
• Innovation Model COVID-19 Adjustments (PDF) (6/3/20)
• List of lab test codes for COVID-19, Influenza, RSV (PDF) (5/12/20)
• Medicare IFC: Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC) (PDF) (3/30/20)
  • IFC Federal Register Announcement (4/1/20)
• COVID-19 Regulations & Waivers To Enable Health System Expansion (PDF) UPDATED (1/19/21)
• Graphic Overview of Flexibilities (PDF) (3/30/20)
• Frequently Asked Questions to Assist Medicare Providers (PDF) UPDATED (3/5/21)
• Provider Burden Relief Frequently Asked Questions (PDF) UPDATED (7/7/20)
• Provider Enrollment Relief Frequently Asked Questions (PDF) (3/30/20)
• Updates for State Surveyors and Accrediting Organizations (EMTALA and Infection Control) (3/30/20)
• Reprioritization of PACE, Medicare Parts C and D Program, and Risk Adjustment Data Validation (RADV) Audit Activities (HPMS Memo) (3/30/20)
• Rural Providers (PDF) (8/20/20)

1135 blanket waivers

What do I need to know about 1135 blanket waivers?

If you’re an entity in the declared emergency area, you can apply for an 1135 waiver. You’ll usually hear back from us within 2-3 days, but if your request is more complicated, it may take up to a week.  If your waiver request has 1 or 2 items, we may get back to you within 24 hours.

Once approved, waivers have a retroactive effective date of March 1, 2020 and will end no later than when the emergency declaration’s ended.

Waivers don’t offer grants or financial assistance.  They also don’t allow you to be paid for services that aren’t usually covered or for people to be eligible for Medicare who aren’t otherwise eligible.  You also shouldn’t base your response decisions, like evacuations, on waivers.  Once your waiver’s approved, as always to be reimbursed accurately, be sure to keep careful records about the services you provide and the beneficiaries you provide them to.  

1812(f) waiver

Approved Coronavirus 1812(f) waiver (PDF)

Other 1135 waivers & 1915(c) waivers

Waiver resources

• Section 1135 Waiver Checklist (3/22/20)
• Section 1915 Waiver, Appendix K Template (3/22/20)

Approved states’ other Coronavirus 1135 waivers

States’ other Coronavirus 1135 waivers

Approved states’ Coronavirus Home & Community Based (HCBS) 1915(c) Appendix K waivers

States’ Coronavirus Emergency Preparedness and Response for HCBS 1915(c) Appendix K waivers

Approved states’ 1115 demonstrations

States’ Medicaid Coronavirus 1115 demonstrations

Medicaid State Plan amendments

States’ Medicaid State Plan amendments

CHIP State Plan amendments

States’ CHIP Plan amendments

Learn more about:

• Flexibilities with 1135 waivers (PDF) 
• Flexibilities without 1135 waivers (PDF)

Find general information about waivers and flexibilities.

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Changes to the Medicare Telehealth Services List Structure and Updates Process

Prior to the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) evaluated changes to the Medicare Telehealth Services List (the List) through an annual rulemaking process. Through this process, CMS considered whether a service met one of two criteria for permanent inclusion on the List. Category 1 services are similar to professional consultations, office visits and office psychiatry services that are currently on the List. Category 2 services are not similar to those on the List—the primary criteria CMS uses in evaluating these services are (a) whether the service is accurately described by the corresponding code when delivered via telehealth and (b) whether the use of a telecommunications system to deliver the service produces demonstrated clinical benefit to the patient. During the PHE, CMS created a third category (Category 3), which allows for temporary coverage while further evidence is developed and the service is considered for permanent (Category 1 or 2) coverage.

The current List structure and updates process have proved cumbersome and confusing to stakeholders, and so CMS finalized simplifying the List into two categories—permanent and provisional—beginning in calendar year (CY) 2024. CMS also finalized the following steps for analyzing changes to the List for the CY 2025 physician fee schedule (PFS) proposed rule:

• Step 1: Determine whether the service is separately payable under the PFS.
• Step 2: Determine whether the service is subject to the provisions of Section 1834(m) of the Social Security Act—in effect, whether at least some elements of the service, when delivered via telehealth, are a substitute for an in-person, face-to-face encounter and all of those face-to-face elements of the service are furnished using an interactive telecommunications system.
• Step 3: Review the elements of the service as described by the HCPCS code, and determine whether each of them is capable of being furnished using an interactive telecommunications system.
• Step 4: Consider whether the service elements of the requested service map to the service elements of a service on the List that has a permanent status described in previous final rulemaking.
• Step 5: Consider whether there is evidence of clinical benefit analogous to the clinical benefit of the in-person service when the patient who is located at a telehealth originating site receives a service furnished by a physician or practitioner located at a distant site using an interactive telecommunications system.

For 2024, CMS finalized its proposal to redesignate Category 1 and Category 2 codes to the new permanent category, and “temporary Category 2” and Category 3 codes to the new provisional category. CMS did not finalize any specific timeline for considering changes from provisional to permanent status—changes in status will be evaluated during the annual updates process.

Additions to the Medicare Telehealth Services List

Each year, CMS reviews requests for changes to the List. This year, CMS is finalizing as proposed a rule to add a series of health and well-being coaching services to the List on a temporary basis for CY 2024. In addition, CMS is finalizing as proposed a rule to add HCPCS code G0136, Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes, to the List on a permanent basis beginning in CY 2024. There were several other requests for additions to the List on a permanent basis, all of which were rejected by CMS in the final rule because they did not meet CMS’ current criteria, described above.

Implementing the Consolidated Appropriations Act (CAA), 2023, Telehealth Provisions

Section 4113 of the CAA, 2023, further extended PHE-related telehealth policies and required CMS to extend PHE-related telehealth flexibilities through December 31, 2024. CMS finalized its proposal to implement several provisions of the CAA, 2023, which would extend the following policies through CY 2024 on a temporary basis:

• In-Person Requirements for Mental Health Services: Delaying the in-person visit requirement for telemental health services furnished by rural health clinics (RHCs) and federally qualified health centers (FQHCs)
• Originating Site and Geographic Restrictions: Expanding the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home
• Eligible Providers: Expanding the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists and qualified audiologists (and adding marriage and family therapists (MFTs) and mental health counselors (MHCs) to the list of eligible providers)
• Audio-Only: Continuing coverage of certain audio-only telehealth services on the List

In addition, CMS finalized extending the following telehealth flexibilities through CY 2024:

• Frequency Limits: Removing frequency limitations for certain subsequent inpatient visits, subsequent nursing facility visits and critical care consultation services
• Direct Supervision of Clinical Staff: Continuing to allow for “direct supervision” to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications (pre-PHE “direct supervision” could only be met via in-person “immediate availability”) (CMS sought comment on whether to extend the flexibilities related to direct supervision and virtual presence of teaching physicians beyond CY 2024 and will consider addressing this topic in possible future rulemaking)
• Telehealth in Teaching Settings: Continuing to allow teaching physicians to have a virtual presence in all teaching settings, but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit with all parties in separate locations)
• Outpatient Therapy, Diabetes Self-Management Training and Medical Nutrition Therapy: Continuing to allow outpatient therapy (physical therapy, occupational therapy, speech-language pathology), diabetes self-management training and medical nutrition therapy to be provided via telehealth when delivered by institutional staff
• Telehealth for Opioid Treatment Providers: Allowing periodic assessments to be furnished via audio-only communications technology when video is not available, to the extent that use of audio-only communications technology is permitted under the applicable Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) requirements at the time the service is furnished and provided that all other applicable requirements are met
• Practitioner Home Address Reporting: In response to provider safety concerns expressed by public commenters regarding the expiration of provider enrollment requirement flexibilities for distant site telehealth practitioners, CMS extended the flexibility to use the practitioner’s currently enrolled location instead of their home address when providing services from their home through CY 2024 and will consider the issue further for future rulemaking.

Changes to Payment by Place of Service for Medicare Telehealth Services

When a physician or practitioner submits a claim for their professional services, including claims for telehealth services, they include a place of service (POS) code that is used to determine whether a service is paid using the facility or non-facility rate. Under the PFS, there are two payment rates for many physicians’ services: the facility rate, which applies when the service is furnished in a hospital or skilled nursing facility setting, and the non-facility rate, which applies when the service is furnished in an office or other setting. The facility rate is typically lower than the non-facility rate, but there is a separate payment to the facility (sometimes called a facility fee), in addition to the payment to the physician, to pay for facility costs (clinical staff, supplies, equipment, overhead).

CMS has evolved its guidance on the use of modifiers and POS codes for telehealth services over the past several years and during the PHE. Starting in CY 2023, CMS required that telehealth claims be billed with one of two POS indicators:

• POS “02”—Telehealth Provided Other Than in Patient’s Home
• POS “10”—Telehealth Provided in Patient’s Home

Beginning in CY 2024, CMS finalized that claims billed with POS 02 be paid at the facility rate and claims billed with POS 10 be paid at the non-facility rate. CMS explains that during the PHE, especially for behavioral health services, practice patterns evolved such that providers often see patients both in person and virtually. As a result, these practitioners continue to maintain their office presence even as a significant proportion of their practice’s utilization may be comprised of telehealth visits. As such, CMS concludes, the practice expenses for these services are more accurately reflected by the non-facility rate. Claims billed with POS 02 will be paid at the facility rate under the logic that those services will be furnished in originating sites that were typical prior to the PHE and the facility rate more accurately reflects the practice expenses of these telehealth services.

CMS noted that it will allow outpatient hospitals and other providers of physical therapy; occupational therapy; and speech-language pathology, diabetic self-management (DSMT) and medical nutrition therapy (MNT) services that remain on the Medicare Telehealth Services List for CY 2024 to bill for these services when furnished remotely in the same way they have been during the COVID-19 PHE and through the end of CY 2023, including that for hospitals, beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services.

In addition, CMS clarified that modifier “95” should be used when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by physical therapists, occupational therapists or speech-language pathologists.

Remote Physiologic and Therapeutic Monitoring

Currently, remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) codes are not stand-alone billable visits in RHCs and FQHCs. When these services are furnished incident to an RHC or FQHC visit, payment is included in the RHC’s all-inclusive rate (AIR) subject to a payment limit or per-visit payment under the FQHC prospective payment system (PPS), which is the lesser of the PPS rate or the FQHC’s actual charges. CMS finalized that starting in CY 2024, RPM and RTM services will be separately payable to RHCs and FQHCs using the general care management code, HCPCS code G0511.

In addition, CMS finalized that RTM services are allowed to be furnished under general rather than direct supervision when provided by occupational therapists (OTs) or physical therapists (PTs) in private practice. Previously, these services, when provided by an occupational or physical therapy assistant, were subject to direct supervision, which required the PT or OT to be “immediately available.” CMS sought comment on whether to allow for general supervision for a broader set of services provided by OTs and PTs and will take these comments into consideration for possible future rulemaking.

Finally, CMS confirmed and clarified the following policies related to RPM and RTM:

• RPM and RTM services can only be furnished to an established patient. Patients who received initial remote monitoring services during the PHE are considered established patients for purposes of the new patient requirements that are now effective after the last day of the COVID-19 PHE.
• 16 days of data are required within a given 30-day period for the relevant RPM and RTM codes. In response to public comments, CMS clarified that CPT codes 99457, 99458, 98980 and 98981 are exempt from this requirement, as they 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.
• RPM and RTM cannot both be billed for the same patient in the same month, though either RPM or RTM can generally be billed with other care management services as long as time or effort is not double-counted.
• RPM or RTM (but not both) can be furnished separately from services covered under payment for a global period as long as time and effort requirements are met.

Request for Information on Digital Therapies

CMS has, over time, expanded coverage for a range of digital therapies, including RPM and RTM. CMS sought information on how remote monitoring services are used in clinical practice and experience with coding and payment policies for these codes, with a focus on digital cognitive behavioral therapy (CBT).

In prior guidance, CMS indicated that digital therapeutics did not have a statutorily defined Medicare benefit category (except for certain digital therapeutics with a hardware component that met the definition of durable medical equipment (DME)), so it is notable that CMS sought comment on how it should view digital therapeutics vis-à-vis benefit category determinations.

In response to public commenters who stated that CMS has existing authority to pay for two types of digital therapeutics—those that meet the definitions of DME and those that are used incident to a physician service—CMS declined to make any changes to coverage but noted that it looks forward to reviewing forthcoming potential code recommendations from the CPT Editorial Panel meeting as part of its standard annual processes and future rulemaking.

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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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HIMSS, a global advocate for digital health transformation, supports a proposed extension of coverage for telehealth services through Dec. 31, 2024.

The reimbursement, at the non-facility rate, was originally scheduled to cease when the federal government ended the COVID-19 public health emergency on May 11, 2023.

More than 150 million people live in federally designated mental health professional shortage areas, and there has been a significant increase in mental health challenges across the world since the beginning of pandemic. HIMSS wrote in public comments submitted to the Centers for Medicare and Medicaid Services on Sept. 11 that removing additional barriers for telehealth services for healthcare providers and patients will have an immediate positive impact on the lives of countless Americans.

The proposed extension allows providers to continue to offer telehealth services while Congress identifies a long-term solution.

CMS published the proposed Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program, on Aug. 12.

The proposed rule included:

• Proposal to reimburse providers for social determinants of health voluntary screenings for Medicare and Medicare Advantage beneficiaries
• Proposal to adopt any changes finalized by the Office of the National Coordinator (ONC) certification program into future iterations of the Promoting Interoperability Program requirements for the Quality Payment Program (QPP) and the Medicare Shared Savings Program (MSSP), without additional rulemaking or public comment opportunities
• Proposal to add one new electronic clinical quality measure to the QPP measure set
• Pause the Appropriate Use Criteria (AUC) program requirements until problems with real time claims data processing can be addressed

HIMSS explained several key points in its response.

With regard to changing certification requirements, HIMSS recommends that CMS allow providers enough time to successfully complete the extensive work required to implement and test the certification changes across their practice, while ensuring quality, safety and patient privacy are not compromised. HIMSS has recommended this will take at least 18 months following the final publication of new certification requirements by ONC, and HIMSS recommends CMS follow the same timeline. HIMSS does not want healthcare providers acting in good faith to be penalized because of insufficient implementation time because of delays associated with standards development, vendor timelines and staffing shortages impacting the healthcare community.

HIMSS supports the pause in the Appropriate Use Criteria program and called for CMS to improve the usability of the AUC clinical decision support mechanisms (CDSMs) to reduce clicks for providers.

HIMSS supports the extension of the telehealth program and called specifically on the importance of providing mental health services via telehealth for patients who do not have face-to-face access to mental health interventions. In addition, HIMSS supports extending the allowance for virtual supervision of resident clinicians in care settings.

HIMSS supports the proposal to reimburse providers for SDOH screenings and called on CMS to clarify the level of licensure required to administer SDOH screenings.

HIMSS called on CMS to publish real-world field-testing data, including the vendors supporting testing sites and the number of testing sites, whenever proposing the inclusion of a new electronic clinical quality measure in the QPP and MSSP measure sets. HIMSS also called on CMS to adopt innovative strategies to incentivize end-user participation in testing programs, as small practices, safety net organizations and not-for-profit care delivery sites often can’t afford to expend the resources needed to participate in testing programs.

HIMSS Public Policy and Advocacy

The HIMSS policy team works closely with the U.S. Congress, federal decision makers, state legislatures and governments, and other organizations to recommend policy, and legislative and regulatory solutions to improve health through information and technology.

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