Key Takeaways for Remote Therapeutic Monitoring in the Final 2023 Medicare Physician Fee Schedule: “General Supervision for all RTM”

As it does every Fall around this time, the Centers for Medicare and Medicaid Services (“CMS”) released its final version of Medicare Physician Fee Schedule for 2023 (the “Final 2023 MPFS”), the regulatory Rule governing payment and coverage policies for physician services, including reimbursement for Remote Therapeutic Monitoring (“RTM”) services under the new CPT code set introduced in 2022. 

Below is an overview of what will change in 2023, for better and for worse.

But first, a brief reminder of how we got where we are today:

In early July, CMS released its Proposed 2023 MPFS, which included changes to payment policy for RTM services aimed at addressing some of the concerns posed by the existing CPT Code set as established by the American Medical Association’s CPT Committee. 

At the heart of these concerns was placement of the CPT Code set for RTM in the Medicine section of the CPT Manual which, in addition to physicians, nurse practitioners, and physician assistants, allowed practitioners like physical therapists and clinical psychologists to independently order and bill for RTM services.

CMS concluded that by placing these codes in the Medicine section rather than the E/M services section of the CPT Manual, the RTM codes could NOT be “designated care management services” codes that allow for time spent by clinical staff to be billed “incident to” a practitioner’s services under “general supervision” – meaning clinical staff need not be present in the same physical location as the billing practitioner. 

What changed for Remote Therapeutic Monitoring from the Proposed Rule to the Final Rule?

We have noted in the past that the ability for medical practices to outsource the monitoring/treatment management component of an RTM program to clinical staff external to their own practice is viewed as critical for success of the program.

The Proposed 2023 MPFS sought to remedy the problem presented by the two RTM treatment management services codes finalized in 2022 by replacing CPT codes 98980 and 98981 with four new HCPCS codes for treatment management services – two for use by physicians, nurse practitioners, and physicians assistants as designated care management services (HCPCS GRTM1 and GRTM2) that may be provided by clinical staff under the general supervision of the billing practitioner, and two for use by Qualified Health Care Practitioners (HCPCS GRTM3 and HCPCS GRTM4) such as physical therapists, occupational therapists, and clinical psychologists. 

In the Final 2023 MPFS, CMS decided NOT to finalize these new HCPCS codes, stating:

“We believe some interested parties may have misinterpreted our proposed valuation of the G-codes, GTRM-3 and GTRM-4. Specifically, we received comments that misunderstood our proposed valuation for GTRM-3 and GTRM-4 to mean that we proposed an across-the-board cut to payment for all Medicare Part B payment for certain types of non-physician practitioners that current[ly] may bill the RTM treatment management codes (CPT codes 98980 and 98981). Based on public comments, we agree that confusion remains about how the new G-codes, if finalized, would or would not possibly create a chilling effect on the availability of RTM services.” – CMS

“General Supervision for all RTM”

Instead, CMS chose to focus its changes on the supervision levels required for clinical staff involvement in and RTM program, stating “General supervision for all RTM services. Any RTM service may be furnished under our general supervision requirements.”

CMS does not attempt to rectify its previously expressed concern that general supervision is not permissible for non-E/M services codes.

Interestingly, Chapter 15, Sec. 230.5 of the Medicare Benefit Policy Manual states: “Incident to a Therapist. There is no coverage for services provided incident to the services of a therapist.”

It is therefore unclear how the policy change in the 2023 Final MPFS permitting general supervision for all RTM services will benefit non-physician Qualified Health Care Practitioners like physical therapists and clinical psychologists. 

The 16-Day Requirement for Remote Therapeutic Monitoring

In the Proposed 2023 MPFS, CMS suggested for the first time that, under the new proposed codes, 16 days of data transmissions would be required in order to bill ANY/ALL of the RTM codes, not just the initial set-up and supply of device codes as had been their past position. Understandably, this caused significant concern among stakeholders who see value in providing treatment management services with fewer than 16 days of data transmitted.

Given CMS’ decision not to finalize the new proposed codes, it appears that this new requirement is now off the table, at least for the time being.

In the Final 2023 PMFS, CMS clearly signals that it expects continued modification of the RPM and RTM code sets, pointing to the CPT Committee’s upcoming consideration of new CPT codes requiring less than 16 days of data collection. 

No Generic Supply of Device Code

Unlike the generic supply of device CPT code 99454 for Remote Physiologic Monitoring (“RPM”) implemented by CMS in 2019, CMS in 2022 finalized two system-specific device codes for Remote Therapeutic Monitoring – CPT code 98976 for supply of a device to monitor the respiratory system, and CPT code 98977 for supply of a device to monitor the musculoskeletal system.

In both the 2022 and the 2023 Proposed MPFS, commenters urged CMS to create a generic supply of device code that would be condition/system agnostic, opening up additional use cases for RTM services.

CMS has declined to do so once again, stating “it remains unclear whether a generic device code would be administrable as a permanent policy, for many reasons” and “it may be difficult to establish an appropriate valuation for a single device code that would reflect the myriad of possible applicable devices.”

This reasoning is somewhat curious given the successful use of a generic device code for RPM services during the past four years. However, CMS notes that it will continue to engage with stakeholders on this issue, leaving the possibility open for a generic RTM device code in the future.

New Cognitive Behavioral Therapy Device Code

CMS did open the door a bit wider for additional RTM use cases by finalizing a new supply of RTM device code for Cognitive Behavioral Therapy Monitoring, CPT code 989X6.

Unfortunately, CMS declined to assign a national reimbursement amount to this code, opting instead to allow the individual Medical Administrative Contractors (the “MACs”) to determine whether/how to reimburse the code. 

The Big Takeaways

CMS’ broad declaration of “General Supervision for all RTM” in the 2023 Final MPFS is a big step forward for RTM services providers and medical practices who want to implement effective Remote Therapeutic Monitoring programs to improve patient outcomes.

While utilizing outsourced clinical staff for monitoring and treatment management services under general supervision of the billing practitioner should be straightforward for physicians, nurse practitioners, and physician assistants, there may be some confusion around how, if at all, this declaration may impact other Qualified Health Care Providers such as PTs, OTs, and psychologists.

The new supply of device code for Cognitive Behavioral Health monitoring is likely to be underutilized due to uncertainty around whether local MACs will reimburse for the code; a generic device code would go much further towards expanding use cases for and adoption of RTM service programs.

Fortunately, CMS has signaled its willingness to work with stakeholders to address continuing concerns around the CPT code set and payment policies for RTM services.

Stay tuned for more on that when we have it!