On February 28, Medicare Administrative Contractors (MACs) contractors—Novitas Solutions (Jurisdictions H and L), First Coast Service Options (Jurisdiction N), Noridian Healthcare Solutions (Jurisdictions E and F), CGS Administrators (Jurisdiction 15), Palmetto GBA (Jurisdictions J and M), and WPS Government Health Administrators (Jurisdictions 5 and 8)—held a multi-jurisdictional Contractor Advisory Committee (CAC) meeting to obtain feedback from a panel of clinicians regarding the strength of published evidence on and the clinical benefits of remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices.
Clinicians spoke about the numerous benefits that RPM and RTM services have to reduce hospitalizations and emergency room visits, advance health equity, and promote value-based care. Considering the increased interest and utilization in remote monitoring services, it is likely that the recent CAC meeting will lead to the publication of a proposed local coverage determination (LCD). When a draft LCD is published, it will be imperative for digital health companies and providers to submit comments to Centers for Medicare & Medicaid Services (CMS) with clinical evidence supporting the benefits of RPM and RTM services to patients.
In the meantime, digital health companies and health care providers that are involved in furnishing remote monitoring services and rely on the RPM or RTM codes should continue to:
- Follow developments in CAC and MAC meetings on remote patient monitoring reimbursement issues;
- Gather evidence to support the clinical necessity and utility of RPM and RTM services they provide and how the use of remote monitoring technology improves patient care and reduces costs and other issues for health care providers and the health system, in general; and
- Compile information to prepare comments in response to the publication of a proposed LCD.
Background on Remote Patient Monitoring
Remote patient monitoring is a form of virtual care that allows providers to monitor and manage their patients’ chronic conditions. Remote patient monitoring services may be used to promote proactive patient self-care, monitor patients’ key measures, provide patients with easy access to guidance about their health issues, and enable physicians to follow their patients’ health. Medicare uses the terms RPM and RTM in their coding and billing language.
Given technological advancements, pandemic-related increases in virtual care, and expanded CMS reimbursement, interest in RPM and RTM services by a variety of health care providers has significantly increased over the past several years. Since 2019, Medicare has seen a significant increase in the utilization of remote monitoring services. Due to the increased interest, MACs have initiated a process that may lead to an implementation of an LCD that would place parameters on the utilization of these services.
RPM services involve monitoring physiological conditions (e.g., weight, blood pressure, blood sugar) through medical devices, which transmit data obtained from patients automatically to health care providers for assessment and recommendations. In 2017, the American Medical Association (AMA) modified an existing code for RPM services and created additional RPM codes as the initial primary category of remote patient monitoring services. The RPM codes became effective in 2019, and CMS clarified several issues in fall 2020 as part of the annual Medicare Physician Fee Schedule rulemaking cycle. The five codes for RPM services are CPT® codes 99091, 99453, 99454, 99457 and 99458. These include two practice-expense-only codes (99453 and 99454) and three codes for treatment management and ongoing monitoring services (99091, 99457 and 99458).
RTM is a family of five codes created by the CPT Editorial Panel in October 2020 and valued by the AMA Relative Value Scale Update Committee at its January 2021 meeting. In contrast to RPM services, RTM services involve the use of medical devices to monitor a patient’s health or response to treatment using non-physiological data. RTM can be used to monitor medication adherence, response to therapy, musculoskeletal activity and respiratory activity. The clinical use cases eligible for reimbursement under RTM are limited to monitoring patients’ musculoskeletal and respiratory systems. The primary difference from RPM relates to who may bill and the nature of the data collected. Effective January 1, 2022, the American Medical Association created five codes for RTM services (98975, 98976, 98977, 98980 and 98981) as a separate category of remote patient monitoring services.
The availability of Medicare reimbursement for RPM and RTM services has led to widespread interest in furnishing remote monitoring services and significant increases in utilization (specifically for CPT codes 99454 and 99457). To date, there have been no established coverage policies for remote monitoring services, including jurisdictional LCDs and a national coverage determination (NCD).
The recent CAC meeting on RPM and RTM is part of the process that could lead to the development of an LCD, which is a decision made by a MAC on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. While NCDs are determined by CMS, LCDs are established by MACs in accordance with section 1862(a)(1)(A) of the Social Security Act. MACs are mandated to base an LCD on robust clinical evidence. Part of the process is to convene subject matter experts as necessary to review the literature and provide input that plays a role in the development of a future coverage decision. The purpose of the CAC meeting is to provide a formal mechanism for health care professionals to be informed of the evidence used in developing an LCD and promote communications between the MACs and the health care community. While CAC panels do not make coverage determinations, MACs benefit from their advice.
During the February 28 meeting, Juan Schaening, First Coast Contractor Medical Director, facilitated the discussion by asking the CAC panel a series of questions on their use of remote patient monitoring that were released prior to the start of the meeting. The panel discussed clinical literature that outlines the benefits that RPM and RTM services to patients and the health care system overall. The panel of around 60 clinicians from various backgrounds (i.e., primary care physicians, physical therapists, orthopedic surgeons, cardiologists, addiction and substance use disorder specialists) overwhelmingly argued that the services should continue to be covered without restrictions, citing benefits of remote patient monitoring services over the standard of care and improved health equity for minority populations.
Moreover, the panel said RPM and RTM improve clinical decision-making, result in better adherence to treatment and patient outcomes, and reduce overall health care costs. Physical therapists and orthopedists spoke about the need to continue Medicare coverage for RTM services and commented that coverage needs to expand, as reimbursement is currently restricted to monitoring patients’ musculoskeletal and respiratory systems. Several members of the panel urged the MACs to continue Medicare coverage of RPM and RTM services, explaining that the impact of coverages of these services will be fully realized during the post-COVID-19 public health emergency period.
Notably, not a single subject matter expert who participated in the call cited any drawbacks to RPM and RTM services. Most explicitly advocated for continued coverage.
If a MAC decides to develop an LCD following the CAC meeting, the proposed LCD will be published on the Medicare Coverage Database and on the MAC’s website. After the proposed LCD is made public, there will be open meetings concerning the proposed policy and a required 45-day notice period prior to implementation of the final LCD. If a draft LCD is published, it will be critical for stakeholders to submit comments to CMS with clinical evidence supporting the benefits of RPM and RTM services to patients.
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