Background
Remote patient monitoring is a set of services involving the collection, analysis, and interpretation of digitally collected physiologic data, followed by the development of a treatment plan, and the managing of a patient under the treatment plan.
The Centers for Medicare and Medicaid Services (CMS) proposed and created RPM codes in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule. The codes provided reimbursement for using technology to monitor patients between visits. Additionally, CMS noted that these services would not be subject to Medicare telehealth restrictions in section 1834(m) of the Act, and the valuation would reflect the resource costs associated with furnishing services utilizing communication technology.
In 2022, CMS further expanded remote monitoring for certain medical specialties, called remote therapeutic monitoring (RTM), to collect non-physiological data.
Top Challenges for Remote Physiologic Monitoring Providers
- Cellular, Wi-Fi, Bluetooth connectivity and transmission service for the device
- Secure and HIPAA compliant software capable of ingesting and processing patient vitals
- Integration with the provider’s electronic medical record
- Two-way patient engagement support software (via SMS, audio, video, or email)
- Compliant time tracking and billing software
- Technical support, device replacement, and battery replacement
- Many others
It is not possible to simply purchase an individual medical device without such features given Medicare’s requirement that, in order to report CPT code 99454, the device must automatically upload a patient’s data, which necessarily means the inclusion of software that must be created and maintained in various ways.
CMS SHOULD CONSIDER THE VARIOUS COMPONENTS REQUIRED FOR A HIGH-QUALITY RPM PROGRAM
CMS’s current valuation of 99454 (monthly remote monitoring, device supply) accounts only for a medical device as a direct practice expense (PE) input. It does not account for the cost of RPM software as a direct PE input. CMS notes, “as the PE data age, these issues involving the use of software and other forms of digital tools become more complex”, and may consider adding software as a direct PE input in the future.
CMS SHOULD INCORPORATE RPM SOFTWARE OR CELLULAR AND WI-FI DEVICE FEES AS DIRECT PRACATICE EXPENSE INPUTS IN VALUING RPM DEVICE SUPPLY CPT CODE 99454
The 20-minute threshold for reimbursement under 99457 and 99458 results in approximately 30% of care being uncompensated. CMS should structure treatment management codes to resemble primary care services by offering reimbursement for care furnished in smaller increments, as opposed to the 20-minute rule. This would improve the long-term viability and reach of RPM.
99453 and 99454 may only be reported once per patient during a 30-day period, even if multiple medical devices are provided to a patient for their conditions. CMS does not permit reporting of multiple instances of 99453 and 99454 when multiple devices are provided to a patient, even when medically necessary. For example, in the case of a patient with type 2 diabetes and hypertension, requires a blood glucose for their diabetes and a blood pressure monitor for their hypertension.
The work RVUs associated with 99457 and 99458 do not accurately reflect the work associated with providing RPM services. The work RVU of 0.61 associated with 99457 and 99458 should be increased to at least match the work RVU associated with chronic care management (CCM) service codes 99490 and 99439, which are 1.0 and 0.70, respectively. The work RVUs associated with RPM codes 99457 and 99458 should increase for the same reasons.
CMS does not reimburse 99457 and 99458 under the Hospital Outpatient Prospective Payment System (OPPS). The lack of reimbursement for 99457 and 99458 means that providers practicing in hospital outpatient department (HOPD) settings are unable to offer RPM services to their patients.
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Upcoming Federal Study
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced it is working on a study: The Use of Remote Patient Monitoring Services in Medicare (OEI-02-23-00260).
The review will be based on Medicare fee-for-service claims and Medicare Advantage (MA) encounter data for remote patient monitoring services. It will look at the extent to which the use of remote patient monitoring services has changed, the nature of remote patient monitoring services being used by Medicare enrollees, and the characteristics of enrollees using remote patient monitoring services. The review will also determine the extent to which provider billing for remote patient monitoring services may indicate fraud, waste, or abuse.