By Brenna E. Jenny and Jaime L.M. Jones

Since 2017, the Centers for Medicare & Medicaid Services (CMS) has taken steps each year to incrementally expand Medicare reimbursement for the work healthcare providers do to monitor their patients remotely. The COVID-19 pandemic accelerated the demand for, and use of, these services. While CMS introduced temporary billing flexibilities to allow for reimbursement in some circumstances, those flexibilities complicate the task of understanding applicable regulatory requirements, rather than immunize providers from scrutiny. The Department of Justice (DOJ) has repeatedly announced that it is prioritizing fraud relating to the pandemic, including abuse of CMS billing flexibilities. The new CMS Unified Program Integrity Contractors (UPICs), which are charged with centralizing federal program integrity auditing, have become more active, including on audits of billing for remote patient monitoring. Healthcare providers should take steps to ensure that their internal billing guidelines and compliance controls remain consistent with CMS expectations, and that claims submitted to Medicare adhere to intended billing policies.

Background on billing for patient monitoring

On November 19, 2021, CMS published its Calendar Year 2022 Physician Fee Schedule Final Rule, which, among other provisions, finalizes reimbursement for five remote therapeutic monitoring (RTM) codes effective January 1, 2022. RTM codes build upon CMS’ work over the past few years to expand reimbursement for remote patient monitoring (RPM). Both RPM and RTM allow certain healthcare providers to bill Medicare for monitoring patients by using medical devices (as defined by the Food and Drug Administration) to gather healthcare data and then analyze it, but the two code sets have some important differences.

RTM covers the collection of non-physiological data, such as information about medication adherence, whereas RPM covers the collection of physiologic data such as blood pressure. However, RTM codes are currently restricted to monitoring patients’ musculoskeletal and respiratory systems, whereas RPM codes do not have any system-specific restrictions. RTM data can be self-reported by the patient, while RPM data must be reported by the medical device back to the provider.

RPM codes are classified as Evaluation and Management (“E/M”) services; therefore, like other E/M codes, only physicians or non-physician practitioners who are eligible to bill Medicare for E/M services can bill for these codes. Clinical staff can also bill “incident-to” the practitioner’s services under general supervision. In contrast, RTM treatment management services are general medicine services, and qualified healthcare professionals as defined in the CPT Codebook — which includes physical therapists, social workers, and physician assistants — can bill using RTM codes. However, incident-to billing is not allowed.

Shifting billing rules for remote patient monitoring
Providers can begin billing Medicare for RTM services on January 1, 2022. Those wishing to expand their patient care services to encompass RTM should keep careful watch on evolving CMS billing rules.

Since CMS began offering separate reimbursement for RPM on January 1, 2018, applicable billing rules have shifted, sometimes, but not always, in response to the pandemic. For example, CMS initially did not permit incident-to billing for any RPM services. However, in the 2019 Physician Fee Schedule Final Rule CMS clarified that incident-to billing would be permitted for treatment management, but only under direct supervision. Frustrated providers pointed out to CMS that requiring direct supervision undermined some of the benefits of remote monitoring, and a year later, CMS authorized general supervision. CMS’s early guidance around RPM was also interpreted by some to mean that RPM services were limited to monitoring chronic conditions. However, during the COVID-19 pandemic, CMS clarified that RPM services can be used to assess acute conditions as well. This clarification is not limited to the pendency of the public health emergency.

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