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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Hospitals across the nation are facing financial constraints and unprecedented staffing shortages. This situation is compounded by the growing need to provide skilled, resource-intensive care for sicker patients being admitted to hospitals’ general care units.

This situation is not only impacting clinical staff, who are overworked, stretched thin and reporting high levels of burnout, but patients, who are more likely to experience a harmful safety event due to inadequate working conditions.

“The intersection of fewer providers and sicker patients is challenging hospitals a great deal,” said Dr. Sam Ajizian, Chief Medical Officer of the Patient Monitoring Operating Unit at Medtronic.

A powerful, impactful strategy to address this challenging landscape is for hospital leaders to leverage technology, specifically remote monitoring, connectivity, and interoperability solutions.

The impact of remote monitoring

Technology — particularly, remote patient monitoring — provides clinical staff with a significant gift: more time with patients.

Right now, clinicians spend far too much of their shift on administrative tasks such as manual charting. They continuously check routine vital signs and manually input the information into the electronic medical record, leading to short, stressful and unsatisfactory interactions with patients.

Remote patient monitoring automates some of this work for caregivers by enabling the continuous capture of vital patient data, which is then uploaded to the EMR and put in the hands of caregivers in the most convenient format for them, such as on a desktop, mobile app or tablet.

As a result, remote patient monitoring can help reduce burnout for clinicians as it decreases the need for manual charting and supports more one-on-one time with patients.

“Remote patient monitoring frees up a lot of nursing hours^3,5 where they can do what they went into the profession for — to talk to patients and give care. No provider went into healthcare to type on a computer,” Ajizian said.

The continuous capture of real-time patient data also allows clinicians to identify adverse patient trends earlier and intervene sooner, helping them improve patient outcomes overall.

In order to gather this data from patients continuously, the monitoring device, such as a wearable, must be comfortable for patients to wear. The BioButton multi-parameter wearable from BioIntellisense, part of Medtronic’s HealthCast portfolio, is small, with a self-adhesive, worn on the patient’s upper left chest, with up to 16 days of battery life. “The BioButton device offers an effortless user experience. Just stick it on and forget it” Ajizian said.   

The important role of connectivity

While the device used to continuously capture patient vital sign information is key to the success of remote patient monitoring programs, so is connectivity. Clinicians must be able to access patient data anytime, anywhere, quickly and easily.

“You can have the best wearable in the world but if the data can’t be displayed where the caregiver wants it and how they want to see it, it’s useless,” Ajizian said.

To achieve this, remote patient monitoring systems should be part of the existing ecosystem of devices and workflows, including the hospital’s EMR.

The HealthCast^TM Vital Sync^TM remote patient monitoring system allows clinicians to remain connected to their patients wherever they are in the hospital. The system is designed to connect to hospitals’ EMRs and existing devices. Additionally, it provides clinicians with actionable insights through near real-time trend and alert data on patients wherever they prefer to see it including via desktop or mobile app.   

The future of remote monitoring

Choosing a remote monitoring platform is a significant financial investment. In addition to considering the product features, hospitals should also factor in the quality of the partnership with the provider.

Hospitals must prioritize finding a partner that will offer long-term clinical, technical, education and maintenance support that puts patients and clinicians first. Medtronic understands the importance of partnering with hospitals to build sustainable remote monitoring programs.

“We meet the customer where they are, we fill in the gaps with the tech and we connect it in the easiest way possible,” Ajizian said.

Learn more about Medtronic’s HealthCast^TM intelligent patient monitoring, a portfolio of remote monitoring, connectivity and interoperable solutions, here.

Footnotes

1. Baker MA, Sands KE, Huang SS, et al. The Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare-Associated Infections. Clin Infect Dis. 2022;74(10):1748-1754.
2. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sentinel-event-general-information-and-2021-update.pdf
3. Bellomo R, Ackerman M, Bailey M, et al. A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards. Crit Care Med. Aug 2012;40(8):2349-61.
4. Stellpflug C, Pierson L, Roloff D, et al. Continuous physiological monitoring improves patient outcomes. Am J Nurs. 2021;121(4):40–46.
5. Han WH, Sohn DK, Hwangbo Y, et al. Effect of a Wireless Vital Sign Monitoring System on the Rapid Response System in the General Ward. J Med Syst. 2022;46(10):64. Published 2022 Aug 26.
6. Downey C, Randell R, Brown J, Jayne DG. Continuous versus intermittent vital signs monitoring using a wearable, wireless patch in patients admitted to surgical wards: pilot cluster randomized controlled trial. J Med Internet. Res. 2018;20(12):e10802
7. Eddahchouri Y, Peelen RV, Koeneman M, Touw HRW, van Goor H, BrediS JH. Effect of continuous wireless vital sign monitoring on unplanned ICU admissions and rapid response team calls: a before-and-after study. Br JAnaesth. May 2022;128(5):857-863.
8. Verrillo SC, Cvach M, Hudson KW, Winters BD. Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients.J Nurs Care Qual. Apr/Jun 2019;34(2):107-113.
9. Weller RS, Foard KL, Harwood TN. Evaluation of a wireless, portable, wearable multi-parameter vital signs monitor in hospitalized neurological and neurosurgical patients. J Clin Monit Comput. Oct 2018;32(5):945-951.

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Executive Summary

Digital health advocates believe remote monitoring—the use of digital technologies to collect and relay patient data to health care professionals—has the potential to transform disease management, health outcomes, and patient care, especially for individuals with multiple chronic conditions who lack convenient access to providers. Medicare, most state Medicaid agencies, and many private health insurance plans cover remote monitoring services.

For the purposes of this report, we define remote monitoring as an umbrella term for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). RPM refers to the monitoring of physiologic data—such as weight, blood glucose, or blood pressure—while RTM refers to the monitoring of patients’ self-reported non-physiologic data, such as pain levels or medication adherence. Currently, the Centers for Medicare & Medicaid Services (CMS) limits RTM reimbursement to cases involving the respiratory system, musculoskeletal system, and cognitive behavioral therapy.

Although the percentage of patients using RPM remains relatively low (594 monthly claims per 100,000 Medicare enrollees in 2021), the use of RPM increased among Medicare beneficiaries more than sixfold from 2018-2021. In part, this increase was due to CMS’ expanded coverage rules during the COVID-19 public health emergency. Thirty-four state Medicaid programs covered RPM services as of March 2023; however, many Medicaid programs restrict RPM use in some way. RTM uptake has also steadily increased since its introduction in 2022, yet billing and documentation requirements can hinder its widespread adoption.

The evidence base on remote monitoring, particularly for RPM tools, is growing. Yet some policy experts cite a lack of robust evidence on the optimal use of remote monitoring, including its duration and target patient groups. In the absence of such evidence, these experts question whether we are effectively “rightsizing” the use of these services. Underuse could limit access to beneficial care, while overuse could unnecessarily increase spending in federal health care programs. Additionally, providers cite the need for tools—such as generative artificial intelligence (AI)—to manage streams of data, otherwise the volume of patient-generated information can become overwhelming and unmanageable.

Over the past year, the Bipartisan Policy Center undertook an extensive effort to develop evidence-based, federal policy recommendations for the appropriate use and coverage of remote monitoring services. BPC assessed patients’ access to and use of remote monitoring technologies and their impact on health outcomes and cost. We conducted a series of interviews and hosted a private roundtable with health policy experts, federal officials, technology leaders, medical providers, payers, consumers, and academics to gain insight into the opportunities and challenges regarding remote monitoring.

This report looks broadly at ways to improve the use of remote monitoring services, ensure equitable access to these services across populations, and enhance data security and privacy standards. Now is the time for payers and providers to refine their approach and maximize appropriate adoption for patients who stand to benefit from remote monitoring.

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The next generation of healthcare will have a face that will likely be much different than anything seen before. The push to rapid innovation, especially in the wake of COVID-19 pandemic, resulted in solutions that provided new outlook in the way healthcare is supervised. As all the industries adjusted to working remotely, healthcare has been more benefitted than most with this shift, where doctors and other clinicians turned to emerging technological solutions in order to keep up with growing demand for healthcare services while keeping patients safe.

Remote Patient Monitoring And Telehealth: The Growth Story

Telehealth had already been a prevailing practice that was beneficial for patients located in remote areas. It was swiftly leveraging technology, providing on-demand consultations to patients. However, the epic pandemic brought its awareness at great extent. It became the silver lining, as government-imposed lockdowns and transmission of the virus restricted physical human interactions. Since in-person visits had to be avoided due to the significant increased risk to patients, telehealth services were rapidly adopted which greatly helped in expanding the access to healthcare. The global telehealth market is likely to witness a growth rate of nearly 24% through 2023-2035.

New solutions to telehealth not only helped healthcare providers to see patients through, but also provided patients with faster, more accurate and complete care. Solutions did not only just expand to texts, phone calls, image forwarding, video consultations, but went further to remote patient monitoring and robust patient health portals. Remote patient monitoring emerged as a significant strategy for telehealth globally, creating robust opportunities for companies that largely dealt outside of the traditional healthcare technology. As per our analysis, the global remote patient monitoring market is estimated to cross a revenue of USD 36 Billion by the end of 2033.

Challenges

Technological innovations have fostered the potential of telehealth. The most effective benefit of telehealth services is the convenience and ease of access, for both healthcare providers and patients. With leveraging technology such as smart wearables and smart home communication systems, telehealth services have improved in the quality and quantity of care provided to consumers. Smart devices provide direct and relevant patient data, and allow constant daily remote monitoring, resulting in obvious benefits to patient care. Along with improved quality, it also improves patient behavior by creating a system where people are more engaged with and responsible for their health. It has also given people a sense of assurance and comfort that someone is watching over their health and well-being on a daily basis.

The Changing Face Of Healthcare

The healthcare industry, today, has created an environment where consumers can demand quality services, lower costs, and easy and convenient access to services. Telehealth has emerged as an innovative and valuable strategy to provide quality healthcare services at lower costs with an easy and effective accessibility. As the most straight-forward initiatives toward revolutionizing digital health, the telehealth market is expanding as new companies are emerging with new and more innovative solutions to improve the potential of telehealth services. Remote patient monitoring is the most effective trend which has changed the competitive and relationship dynamics of telehealth industry, and will continue to be very active as the industry expands with new solutions coming in together. Some of the recent trends that is predicted to shape the future of telehealth services are:

• Telemedicine program in the United States are rendered by over 51% healthcare organizations.
• Telehealth improves the service quality of the treatment provided to the patients, claims about 50% of the healthcare organizations globally.
• While deciding for treatment, more than 55% of the patients feel that their involvement has increased significantly in the decision-making process as a result of the benefits associated with telehealth.

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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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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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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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“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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Federally qualified health centers (FQHCs) are an important safety net for individuals who often do not have easy access to primary and preventive care. With a mission to ensure the delivery of high-quality, comprehensive health care services to these underserved communities, many FQHCs are now choosing to leverage technology – like remote patient monitoring (RPM) – to reach more individuals and take a proactive approach to their care that results in better outcomes and minimizes health care overall costs.

RPM’s role in improving access to care

Since the COVID-19 pandemic, incorporating RPM into a patient’s care has proven extremely effective for FQHCs. Services can be extended beyond traditional in-person visits, which is particularly important when monitoring patients for high blood pressure, diabetes, heart failure, asthma and other chronic conditions. The patient-generated data also enhances continuity of care, allowing clinicians to identify potential red flags before they escalate into more complicated problems. By having a holistic view of the patient and taking proactive measures, FQHCs can ultimately reduce overall health care costs for both the patients and payers.

Yet, despite the early successes with RPM deployments and the obvious benefits from the initial grant funding FQHCs received for RPM projects and specific disease management initiatives during the pandemic, FQHCs still face significant uncertainty about how to pay for these beneficial programs long term, as those grants are limited in scope and duration.

Overcoming current obstacles in RPM reimbursement

As the reimbursement currently stands, Medicare does not reimburse FQHCs or rural health centers (RHCs) for RPM activity. Additionally, Medicaid coverage varies greatly by state. Currently, 34 state Medicaid programs provide RPM reimbursements, but this coverage often does not include FQHCs. Many Medicaid programs also have restrictions – such as limiting the types of clinical conditions for which symptoms can be monitored, the devices used and the information that can be collected.

To keep RPM programs running, and potentially consider expanding their use, FQHCs have needed to find creative ways to pay for them. Among the approaches are:

• Incorporating into chronic care management (CCM) – CCM code G0511 is a Medicare service designed to support patients with multiple chronic conditions by providing non-face-to-face care coordination and management for those with substantial health care needs. Often patients who could benefit from RPM also have multiple comorbid chronic conditions. The revenue from CCM services for these patients could help sustain RPM programs.
• Generating additional in person visits according to medical necessity based on RPM data – The CMS Prospective Payment System (PPS) payment model reimburses FQHCs based on a predetermined, fixed rate per patient visit or encounter. The intent of PPS is to cover the costs of providing a comprehensive range of primary and preventive health care services so that FQHCs have a stable and predictable funding source to provide essential, appropriate health care services to their communities. In some cases, these payments can help support RPM programs. For example, TrueCare in San Diego indicated that PPS reimbursements will help sustain its current, successful RPM program for hypertension if engagement in the program results in one extra in-person visit for every 13 patients using RPM. These in-clinic visits are often needed to assess symptoms, complications or medication adjustments that are identified through the RPM program.
• Bolstering grant applications with data on patient outcome improvements – Grants play an important role in enabling FQHCs to support patients and employ state-of-the-art solutions. FQHCs with existing RPM programs should leverage the data they collect and track patient progress to show the positive impact of remote monitoring on patient outcomes. Real-world results and examples of successful deployments will strengthen the case for FQHCs to win grants to continue support, or enhance, RPM programs. For example, a large FQHC in California was able to build their RPM program through successive grants leveraging outcomes achieved. After their initial Hypertension grant from HRSA in 2021, the FQHC was able to secure an Optimizing Virtual Care (OVC) Grant in 2022, which allowed them to expand RPM to diabetes. When submitting for the OVC grant, they used the success of their hypertension pilot program.

New hope for Medicare reimbursements for RPM at FQHCs in 2024

While these efforts may help sustain existing programs, there are indications that changes are on the horizon to make RPM reimbursements more impactful. Changes to current reimbursement presented in the 2024 Proposed Physician Fee Schedule (PFS) would allow for reimbursements to FQHCs for RPM services for Medicare beneficiaries. While this does not dictate coverage for Medicaid beneficiaries, and there is some concern that billing for RPM under the same G0511 code as CCM will not provide enough sustainability for RPM activities, it’s a starting point. If Medicare does expand eligibility for RPM reimbursement to FQHCs, it is anticipated that many Medicaid plans may follow suit. This would create a sustainable model for RPM programs at FQHCs and provide needed support to many individuals who receive their care through these community health clinics. Many stakeholders provided robust feedback to CMS’s proposed PFS and anxiously await the 2024 PFS Final Rule in early November.

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