It's not unusual for the yearly physician fee schedule final rule published by the Centers for Medicare & Medicaid Services (CMS) to include rule changes that are open to some level of interpretation.
But this often brings confusion about what CMS expects billing providers and organizations to do to comply with coding and billing regulations. When this happens, it's typically a matter of time (i.e., future final rules) until CMS further clarifies the rules.
The new remote patient monitoring regulations in this year's rule were especially vague and sometimes even contradictory. Luckily, in an unusual development, CMS released an update that corrects and clarifies some significant areas of confusion in its 2021 Medicare physician fee schedule final rule concerning remote patient monitoring billing requirements.
Providers with remote patient monitoring/remote physiological monitoring (RPM) programs will want to understand these changes for a few reasons. First and foremost, unlike the normal multiple-month final rule development process and advanced notice we have before final rule changes take effect, these revisions took effect on the date of their publication: January 19. As such, RPM providers must evaluate how they are currently billing for RPM to account for these changes, if necessary.
Second, the final 2021 rule and correction update make clear that the way some providers interpreted the 2020 final rule was not what Medicare intended. It is worthwhile for providers to review how they have already billed for remote patient monitoring to determine whether any claims submitted in 2020 are likely to have violated the clarified rules. Even if providers can make a strong argument that they used a good-faith and reasonable interpretation of the rules as they stood at the time of billing, it is essential to assess and qualify possible issues and risks moving forward.
Third, the corrections and clarifications bring some very good news for providers delivering remote patient monitoring services or those thinking about launching RPM programs.
Let's review the three most significant revisions to RPM.
1. Clarification concerning “interactive communication” definition and requirements in CPT 99457 and 99458
CMS clarified that the 20 minutes of time associated with billing CPT codes 99457 and 99458 should include care management services and synchronous, real-time interactions. In other words, the "interactive communication" that CMS previously defined contributes to the total time but is no longer the sole activity that should be included in the total time.
CMS states in the correction document that "… the 20-minutes of intra-service work associated with CPT codes 99457 and 99458 includes a practitioner's time engaged in 'interactive communication' as well as time engaged in non-face-to-face care management services during a calendar month."
Although CMS states that some amount of monthly "interactive communication" (i.e., telephone or video conferencing) is required, it does not specify the reasonable or expected proportion of such communication in each 20-minute code.
The big news here is that RPM providers can now bill CMS for both interactive communications and remote care services rendered under CPT 99457 or 99458. Each 20-minute code can now be comprised of chart review, care planning, and patient messaging as well as real-time audio communication.
2. Clarification concerning 2-day and 16-day requirements
For most of the past year, there has been significant confusion around the number of measurement-days required to bill CPT codes 99453 and 99454. The source of the confusion is a waiver issued during the COVID-19 public health emergency (PHE). This waiver permitted providers to deliver and bill for remote patient monitoring services to patients with suspected or confirmed cases of COVID-19. In such instances, RPM providers could bill for services as long as they were provided (i.e., measurements were taken on an RPM device) for at least two days. This was generally referred to as the “2-day requirement.”
Language in the final rule did not clearly associate the 2-day requirement with patients having suspected or confirmed cases of COVID-19. This led some to interpret that the 2-day requirement could apply to all patients during the PHE.
While the correction document does not specifically mention such COVID-19 patients, the PHE, or the aforementioned waiver, CMS does seek to clarify what is currently required for RPM billing. The clarification document states the following: "The medically necessary services associated with all the medical devices for a single patient can be billed … when at least 16 days of data have been collected."
CMS's emphasis on "16 days" should be interpreted to mean that this figure — as opposed to 2 days — is the current default requirement. Thus, only those exceptions actually identified under the PHE waiver are acceptable for the 2-day requirement.
3. Clarification concerning number of practitioners who can deliver RPM services
CMS clarified, or one might say reiterated, that only a single practitioner can bill CPT codes 99453 and 99454 during a 30-day period. This departs from the generally accepted interpretation of the 2020 final rule, where it was inferred that more than one provider could bill for the same patient for different RPM devices (e.g., cardiologist monitors blood pressure readings while a gastroenterologist or bariatrician monitors weight).
With this clarification, providers will want to identify whether potential remote patient monitoring patients are already receiving RPM services from another provider before initiating new RPM services.
Access the correction document here.
Expectations for future of remote patient monitoring
The correction document is not just good news for remote patient monitoring in 2021, but it also bodes well for the long-term prospects of RPM. Although CMS has made more explicit some aspects of RPM, it also reaffirmed its support and plans for future expansion for RPM in the 2021 rule commentary.
We expect that Medicare will further clarify the remaining blurry margins about what qualifies for RPM to avoid abuse while continuing to expand the overall scope and coverage of the program, which undoubtedly is a win-win for providers and patients.
Daniel Tashnek is the founder of Prevounce Health. Prevounce is a cloud-based platform that supports organizations in their delivery of remote patient monitoring services as well as chronic care management, annual wellness visits, and preventive services.