As 5 principais regras para o Medicare 2024 Monitorização remota de doentes e monitorização terapêutica remota: O que as empresas precisam de saber

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.

Esclarecimentos sobre RPM e RTM

O RPM só pode ser fornecido a um "doente estabelecido"

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.

Conclusão

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.

Quer saber mais?

Para obter mais informações sobre telemedicina, telessaúde, cuidados virtuais, monitorização remota de doentes, saúde digital e outras inovações na área da saúde, incluindo a equipa, as publicações e a experiência dos representantes, visite a Telemedicine & Digital Health Industry Team da Foley.

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