On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) proposed five new changes to Remote Therapeutic Monitoring (RTM) services under the Medicare program. The changes, part of the proposed 2023 Medicare Physician Fee Schedule rule, have been anticipated by digital health providers hoping to see more clarity and flexibility for RTM services. In this year's proposed rule, CMS built upon its 2022 introduction of new RTM codes (CPT Codes 98975, 98976, 98977, 98980, and 98981).
The rule, if enacted as proposed, will:
- Introduce four new RTM codes, with one pair intended for use by physicians or non-physician practitioners (NPPs) and the other pair intended for use by non-physician qualified health care professionals (QHPs);
- Allow RTM services billed under a physician or NPP's Medicare enrollment to be furnished by clinical staff under general supervision, rather than direct supervision;
- Clarify certain prerequisites for billing certain RTM codes;
- Postpone the creation of a general device code for RTM; and
- Introduce a new contract-priced RTM device code for cognitive behavioral therapy.
Four New RTM Codes Introduced
When the RTM codes were originally created, some practitioners were confused how the codes applied to non-physician QHPs (e.g., physical therapists, occupational therapists, speech language pathologists, licensed clinical social workers, certified registered nurse assistants), as the codes were classified under the "General Medicine" category, not the "E/M Services" category. Practitioners were uncertain if any portion of RTM could be performed by clinical staff incident to the services of the billing practitioner and, if so, the level of supervision required by the billing practitioner.
In response, CMS proposed to replace two of the current RTM codes (CPTs 98980 and 98981) with four new HCPCS G codes that specify if the RTM services are delivered by a physician or NPP versus a non-physician QHP. (G codes are temporary codes assigned to services and procedures that are under review prior to being included in the CPT codes.)
The proposed RTM codes are:
- HCPCS code GRTM1 (Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes of evaluation and management services).
- HCPCS code GRTM2 (Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver over a calendar month; each additional 20 minutes of evaluation and management services during the calendar month (List separately in additional [sic] to code for primary procedure).
- HCPCS code GRTM3 (Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a non-physician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month).
- HCPCS code GRTM4 (Remote therapeutic monitoring treatment assessment services, additional 20 minutes furnished personally/directly by a non-physician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month (List separately in addition to code for primary procedure)).
Based on the code descriptors and CMS commentary, it appears GRTM1 and GRTM2 are reserved for physicians and NPPs whereas GRTM3 and GRTM4 are for non-physician QHPs.
By separating codes by practitioner type, the RTM codes for physicians and NPPs can harness more flexible billing models (e.g., billing Medicare for "incident to" services provided under general supervision). The RTM codes for non-physician QHPs generally must be furnished directly by the billing practitioner. If these new HCPCS codes are adopted, the current codes CPTs 98980 and 98981 would become non-payable by Medicare (because they would be replaced by the HCPCS codes).
RTM Furnished Under General Supervision
Under the proposed rule, HCPCS code GRTM1 and GRTM2 may be furnished under general supervision, rather than direct supervision. Direct supervision means the physician and clinical staff must be in the same building at the same time (albeit not the same room). General supervision does not require the physician and clinical staff to be in the same building at the same time, and the physician could instead use telemedicine technologies to exert general supervision over the clinical staff. Changing the RTM rules to expressly allow incident to billing of GRTM1 and GRTM2 under general supervision greatly expands the potential operations and business models associated with RTM services when utilized by physicians or NPPs.
Clarification on RTM Billing Requirements
Prior to the proposed rule, CMS had not published express guidance on whether the RTM professional codes could only be billed in combination with an accompanying RTM device code, or if the RTM professional codes could be billed even if the device fails to collect at least 16 days of data monitoring.
In the proposed rule, CMS stated the RTM device codes (CPTs 98975, 98976, 98977) must be billed prior to reporting the RTM professional codes (GRTM1, GRTM2, GRTM3, GRTM4). Moreover, if at least 16 days of data are not reported during a 30 day period, the professional codes may not be billed for that period. In other words, all requirements of the RTM device codes must be met in order to bill the RTM professional codes. If this proposed clarification is finalized, the RTM professional codes could not be used to manage the treatment of a condition where codes other than CPT codes 98985 and 98976/98977 were used to collect the data or if the monitoring services did not include at least 16 days of data.
CMS also stated the physician/NPP RTM professional codes (GRTM1, GRTM2) cannot be billed in conjunction with the non-physician qualified health care professional codes (GRTM3, GRTM4). For example, a physician could not bill RTM with a physical therapist also billing RTM for the same patient.
No Generic Device Code
The current RTM device supply codes (CPTs 98976, 98977) are limited to transmissions for monitoring the respiratory or the musculoskeletal systems. These codes do not target other systems (e.g., neurological, vascular, endocrine, digestive, etc.), which has limited the use cases for RTM.
In the proposed rule, CMS acknowledged receipt of requests to develop a generic device code for RTM to broadly apply to all conditions/systems. CMS declined to create such a code, stating it will wait and instead seek comments to inform any new coding relating to devices. Accordingly, CMS requests information and comments related to the types of data collected using RTM devices, how the data that are collected to solve specific health conditions and what those health conditions are, the costs associated with RTM devices that are available to collect RTM data, how long the typical episode of care by condition type might last, and the potential number of beneficiaries for whom an RTM device might be used by the health condition type. Such comments can be submitted now by interested stakeholders.
New Contract-Priced Cognitive Behavioral Therapy Monitoring Device Code
In 2021, the American Medical Association's (AMA) CPT Editorial Panel created a new CPT code 989X6 to code for Cognitive Behavioral Therapy (CBT) monitoring services. The proposed new code reads as follows:
Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavioral therapy, each 30 days).
Based on the AMA's recommendation, CMS proposes to contractor price the CBT device code for 2023. Contractor priced status means the new CBT device code value and payment would be established at the discretion of each local Medicare Administrative Contractor (MAC) and could vary nationally. Practitioners will need to refer to their local MACs for specific coverage and billing guidelines of the new CBT device code. CMS cited a dearth of information currently available about devices useable with this code as the rationale for its decision to contractor price the CBT device code.
What to Do Next?
Providers, health technology companies, and virtual care entrepreneurs interested in RTM can consider providing comments to the proposed rule. CMS is soliciting comments on the proposed rule until 5:00 p.m. ET on September 6, 2022. Anyone may submit comments – anonymously or otherwise – via electronic submission at this link. Alternatively, commenters may submit comments by mail to:
- Regular Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1770-P, P.O. Box 8016, Baltimore, MD 21244-8016.
- Express Overnight Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1770-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850
If submitting via mail, be sure to allow time for comments to be received before the closing date.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
