By Adriana Krasniansky
New reimbursement codes for virtual patient monitoring may soon be incorporated into Medicare’s fee schedule, signaling the continued expansion and reach of digital health technologies catalyzed by the COVID-19 pandemic.
In July 2021, the Centers for Medicare & Medicaid Services (CMS) proposed adding a new class of current procedural terminology (CPT) codes under the category of “remote therapeutic monitoring” in its Medicare Physician Fee Schedule for 2022 — with a window for public comments until September 13, 2021. While this announcement may seem like a niche piece of health care news, it signals a next-phase evolution for virtual care in the U.S. health system, increasing access possibilities for patients nationwide.
Remote Monitoring and the COVID-19 Pandemic
In 2020, during the COVID-19 pandemic, virtual care saw a 20-fold increase in use across the United States. Providers and policymakers rushed into action to evolve health care regulations and reimbursement policies to keep up with patients’ changing behaviors.
One critical area of focus was remote patient monitoring (RPM), a term for the collection and interpretation of physiological patient data by digital devices. These insights are integrated into electronic medical records (EMR) and used to inform clinical care decisions.
When patients, especially chronic care patients, could not attend their regular appointments during the pandemic, RPM technologies provided a pathway for clinicians to monitor their health from afar. RPM devices that gained traction during the pandemic included connected blood pressure monitors, glucose monitors, scales, and pulse oximeters.
However, the pandemic also spotlighted key policy ambiguities that limited certain patients’ RPM use during the pandemic.
First, RPM codes can only be used in conjunction with approved medical devices that track baseline physiologic data like heart rate, blood pressure, and blood sugar levels. Patients who need to track other data points, such as mood, pain levels, therapy adherence, or medication side effects, cannot have their digital tracking reimbursed through RPM codes.
Next, only certain clinicians — mainly physicians — can bill for some RPM codes, while others, such as therapists or nurse practitioners, cannot. This skews RPM coverage away from respiratory care, musculoskeletal (MSK) care, mental health support, and other therapeutic areas that are often handled by therapists.
Finally, RPM data must be collected directly through a connected device and cannot be self-reported by a patient, which can be difficult for patients who have limited broadband access at home.
Together, these RPM coverage gaps drove several medical professionals (including Andrey Ostrovsky, former Chief Medical Officer of the U.S. Medicaid Program) to call for the expansion of RPM reimbursement coverage post-pandemic.
3/ Remaining ambiguities around reimbursement (especially sustainability) prevents the delivery of effective, socially distanced care for multiple conditions, which could exacerbate inequitable access to #digital tools
— Andrey Ostrovsky, MD, FAAP (@AndreyOstrovsky) March 21, 2021
Introducing Remote Therapeutic Monitoring
In response, the American Medical Association (AMA), which manages the full library of CPT codes, proposed a new class of reimbursement codes titled “remote therapeutic monitoring” (RTM), which have been included in CMS’s CY 2022 Medicare Physician Fee Schedule.
For code fiends out there, the proposed codes are numbered CPT 989X1, 989X2, 989X3, 989X4, and 989X5. Services covered by these RTM codes include initial setup, patient education, device supply, and treatment management.
RTM codes differ from RPM codes in a few key ways:
- RTM codes allow for self-reported data input. RPM codes require that data be directly uploaded from a medical device, but under RTM, patient data can be self-reported. This means that patients can log their own data into RTM portals. While RTM codes still require a medical device, these self-reported data permissions suggest a possible future shift to more app- or smartphone-based remote monitoring. As a bonus: mobile apps don’t require as strong of in-home broadband connections as connected devices, which works around the current U.S. broadband gap.
- RTM codes allow for non-physiologic data collection. Under RTM, more data around indicators such as pain level, therapy/medication adherence, and therapy/medication response can be collected and billed for. Broader data collection means that clinicians will have more holistic views of their patients’ health, and, in the long-term, clinical researchers will have better population-wide insights into “subjective” health outcomes such as pain.
- Nurses and therapists can bill for RTM. CMS has suggested that nurses and physical therapists be the primary billers of RTM codes. This is especially important for expanding remote monitoring options in communities where physician access is limited, or for conditions where a majority of services are offered by therapists and nurses, rather than physicians.
Remaining Questions and the Future of Remote Monitoring
Even with the introduction of RTM codes, questions remain around the full coverage possibilities around remote monitoring.
For example, the RTM code descriptions list certain examples of conditions that can be monitored under RTM: respiratory system status, musculoskeletal (MSK) system status, therapy adherence, and therapy response. While these descriptions pave the way for scaling digital health solutions in respiratory care (e.g., connected inhalers and spirometers), medication adherence (e.g., smart pill bottles), and joint and muscle pain (e.g., virtual MSK programs), it leaves unanswered questions about how our health system will virtually support patients managing mental health, oncology, sleep, and substance use disorder needs.
While CPT codes may seem like a minor component of the health care system, they can make or break whether a medical therapy reaches its full patient community. Because CPT codes inform whether a therapy qualifies for reimbursement, code designation affects providers’ likelihood to prescribe remote monitoring technologies. Plus, reimbursement reduces out-of-pocket costs for patients. In a world where digital health makes up a growing proportion of overall health care innovation, patient access and utilization through CPT codes will be key to the equitable expansion of digital health.
The target effective date for CY 2022 Medicare Physician Fee Schedule is January 1, 2022, and CMS is accepting public comments on the fee schedule until September 13, 2021. In regard to RTM, CMS is specifically seeking comments on the types of devices that might be used to collect RTM data and suggestions for how to construct RTM codes for non-physician practitioners.
If you’re interested in taking a more active role in digital health coding and reimbursement, the AMA is adding four new CPT Editorial Panel Seats to support “content advances to reflect the emergence of digital health, diagnostic precision medicine and augmented intelligence.”