CMS 2024 Updates and Changes for Remote Care Services

On November 2, 2023, CMS released its final 2024 Physician fee schedule and final rule on policies related to remote care management. Overall, the focus for 2024 changes were on increasing health equity and access, increasing behavioral health access, improvements in oncology and diabetes prevention. As well as creating greater transparency in hospital pricing. 

Specific 2024 updates and changes regarding remote care management focus on finalized new policies related to remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services reimbursed under the Medicare program. While the 2024 changes for remote services have no new CPT codes, CMS addresses some remaining ambiguities for RPM and RTM regulations - including rules for PTs and OTs, data requirements, coverage expansion, and more.

CMS continues to advance the ability of RPM and RTM services to drive revenue and improve the patient care experience. The 2024 Final Rule addresses billing scenarios and requests for clarifications on the appropriate use of these remote monitoring codes, and clarifies CMS’ position on how it interprets certain requirements for these services. 

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Key Takeaways from CMS on the updates impacting RPM and RTM programs

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RPM and RTM established patient requirements 

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. So Medicare patients who received initial RPM services during the PHE will be “grandfathered” in - and will be considered established patients. Patients beginning 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. 

It’s important to note, however, that Medsien’s policy has always been to require an E/M visit prior to enrolling patients - even during the PHE  - to ensure increased compliance. 

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RTM Technically Does Not Contain an “Established Patient” Requirement

While RPM services require an established patient relationship prior to billing RPM codes, RTM technically do not. CMS confirmed in the 2024 Final Rule, “RPM, not RTM, services require an established patient relationship after the end of the PHE.” However, 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. Again, however, it’s important to note that Medsien has consistently maintained this requirement regardless to ensure better compliance and patient engagement. 

Use of RPM or RTM with other patient care management 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 as 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). 

Medsien is extremely sensitive and aware of the importance of hyper-compliance in complex remote care programs and billing. In an effort to ensure this - increased compliance and distinct, separate data tracking - Medsien enrolls patients in only one program at a time. 

 16-Day monitoring not required for RPM or RTM treatment management

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 do not. There was some confusion due to an error in the language in the proposed changes released in July,  leaving some ambiguity as to whether or not the 16-day requirement applied to the four treatment management codes (CPT codes 99457, 99458, 98980, and 98981).  In the 2024 Final Rule, CMS notes 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 or RTM device data collection 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.”

When reiterating that only one practitioner can bill these codes, CMS did not 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. CMS will need to clarify in future rulemaking updates, 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.

Billing RPM or RTM during global surgery periods

For 2024, CMS clarified that providers receiving a global service payment, may not bill for RPM or RTM services.  When a billing practitioner furnishes a procedure or surgery subject to a global billing period they cannot bill Medicare for RPM or RTM services provided to the patient during that global period, because the global billing payment received by the practitioner covers those post-surgical follow-up services during the period. 

However, practitioners, such as physical or occupational therapists, who are not receiving a global service payment because they did not furnish the global procedure, are permitted to provide RPM or RTM services during a global period. 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.

Also, for a patient already 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 the global procedure is performed, and as long as the purpose of the remote monitoring addresses an episode of care that is separate and distinct from the episode of care for the global procedure – meaning that the remote monitoring services address an underlying condition that is not linked to the global procedure or service.

FQHCs and RHCs may receive separate reimbursement for RPM and RTM services

CMS has finalized that starting in 2024, FQHCs and RHCs will be able to separately bill Medicare for RPM and RTM, using the general care management code (HCPCS code G0511). 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. 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.

RHCs and FQHCs may bill HCPCS code G0511 multiple times in a calendar month, 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. Expansion of RTM services to RHCs and FQHCs improves access to healthcare for underserved populations in remote areas, supports early intervention of conservative treatments, and promotes health equity. 

Physical therapists and occupational therapists can bill RTM for assistants under general supervision outside of private practice

This is a very important provision that allows Physical Therapists (PTs) and Occupational Therapists (OTs) in private practice to provide general supervision for RTM services furnished by their PTAs and OTAs, respectively. Physical therapists and occupational therapists 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 supervision of, 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. This supports RTM management services to be performed outside of the clinic, which is instrumental to providing comprehensive at-home support for patients. 

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.

The 2024 Final Rule reflects a continued maturation of RPM and RTM Medicare billing guidance. At Medsien, we closely monitor, update and incorporate any CMS changes into our systems, so they are ready to go on January 1, 2024. Compliance and accuracy is at the core of our programs and CMS changes and other policies impacting remote care management programs will always be a top priority to how we build and update our programs. Talk to us about how we can help you to incorporate the CMS 2024 final rule into your practice.  

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Sources: 

CMS 2024 Final Rule:

https://public-inspection.federalregister.gov/2023-24184.pdf

CMS 2024 Final Rule Fact Sheets and Announcements: 

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule

https://www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-rule-advances-health-equity

https://www.cms.gov/newsroom/press-releases/cms-makes-hospital-prices-more-transparent-and-expands-access-behavioral-health-care

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program