US Reimbursement for RPM (Remote Patient Monitoring) Ctd. – CY 2021 Physician Fee Schedule Final Rule

In our previous discussion about US RPM reimbursement policy, we broke down CMS’s proposed changes to the Medicare Fee Physician Schedule. Since then, on December 1st, CMS released the CY 2021 Physician Fee Schedule Final Rule. Some of the self-stated goals for the final rule were to “identify who can furnish RPM services, what kinds of devices can be used to collect data, how data should be collected, and how “interactive communication” is defined.” The final rule reaffirmed many of the proposed changes from August, but also included some more recent changes that will be addressed below.

First, here’s a quick reminder of what the 5 primary RPM codes are and their uses:

• 99453 addresses the cost of setting a patient up with RPM
  • “Initial; set-up and patient education on use of equipment.”
• 99454 addresses the monthly costs associated with operating an RPM program
  • “Initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
• 99457 addresses the cost of time spent communicating with the patient
  • “20 minutes or more of clinical staff/physicians/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
• 99458 is an add-on to 99457 for additional time spent communicating
  • “Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes”
• 99091 is an older code that can replace (or as new language suggests, even be billed in addition to) 99457 for collection and interpretation of RPM data
  • “Collection and interpretation of physiologic data… digitally stored and/or transmitted by the patient… to the physician…”

Now let’s discuss what the final rule reaffirmed.

• RPM services can be provided to patients with chronic AND acute conditions. This change was initially implemented as part of the response to the public health emergency (PHE) in March, and has now been solidified by CMS. Particularly in relation to remote monitoring programs for discharged COVID-19 patients, this detail is critical. Hospitals can be reassured that they will be able to continue to monitor these patients into 2021 and still receive reimbursement for their services.
• RPM services can be furnished by auxiliary personnel. While RPM services can only be billed for by physicians or other qualified health care professionals who are authorized to independently bill Medicare for the service, other personnel, such as clinical staff, can furnish RPM services. The clinical staff members must be under “general supervision” of the qualified HCP. This rule opens up a wide array of staffing flexibilities for hospitals, particularly important during the COVID-19 era when staffing is such a tightly constrained resource.
• Devices used for RPM services do not have to be FDA approved. While it may be appropriate, there is “no language in the CPT Codebook indicating that a medical device must be FDA cleared…”. In order to bill for code 99454, the device(s) used must meet the FDA definition of a medical device, and should “digitally upload patient physiologic data” (rather than it being self-recorded by the patient.) This language still suggests a fair bit of leniency in terms of what devices can be used, and may encourage the use of a wider variety of novel devices.
• Consent can be obtained at the time that RPM services are furnished. Consent can also be obtained by auxiliary personnel as described above.

As mentioned earlier, there were a couple of changes to the final rule, no doubt some of which came in response to the feedback received on the proposed changes from August.

The time spent on “interactive communication” used to bill for 99457 and 99458 may now include other activities, though the details remain unclear. After much uncertainty around what constitutes “interactive communication” for codes 99457 and 99458, CMS attempted to clarify things in the 2021 PFS proposal. They specified that interactive communication involves “a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.” They also doubled-down on the idea that there must be 20 minutes of interactive communication itself, and that other related activities can not be included in this time.

After significant push back from the industry, pointing out the inconsistency of this rule when compared to requirements for similar codes, CMS seems to have changed their mind. In an additional Fact Sheet released in conjunction with the final rule, CMS writes “…We further clarified that the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.” This language is inconsistent with the final rule itself, where it stands by the idea that the 20 minutes must be strictly time spent communicating with the patient.

As Wein, Ferrante, Goodman, and Lacktman point out in their thorough and insightful FAQ, the 2021 Final Rule will not be published in the Federal Register until December 28th, so there is still time for CMS to amend this inconsistency. Until then, we can only hope that CMS will indeed change their mind on this important issue. The successful roll-out of remote patient monitoring is dependent on clinicians and hospitals being able to efficiently and effectively bill for these services, and this change would go a long way in getting us there.

99457 and 99091 may now be billed in the same period. It states in the CPT Codebook, “Do not report 99091 in conjunction with 99457.” However, in the final rule, CMS points out that another section of the Codebook states, “Do not report 99091 for time in a calendar month when used to meet the criteria for …, 99457…” Rather confusingly, they write, “We note that these two statements suggest that there may be instances where both codes could be billed for the same patient in the same month as long as the same time was not used to meet the criteria for both CPT codes 99091 and 99457.”

Their justification goes as follows. CPT code 99091 includes a total of 40 minutes or clinician time: “…5 minutes of pre-service work…” (i.e. chart review), “…30 minutes of intra-services work…” (i.e. data analysis and interpretation), “…and 5 minutes of post-services work…” (i.e. charting). When further interpretation and analysis is required by a clinician outside of the time already allotted to 99091, it may be appropriate to bill for both 99091 and 99457 in the 30 day period.

While potentially advantageous to hospitals who are billing for RPM services to use both in the same period, it is still relatively confusing how exactly the time is supposed to be reported. Furthermore, it explicitly states in the Codebook that they are intended to be billed exclusively from each other. Therefore, CMS must adjust the language in the Codebook if they intend to keep this change.

What’s next for RPM billing?

Overall, the outlook for RPM billing policy continues to be increasingly positive. By solidifying many of the changes made during the PHE, it’s clear that CMS has no intention of reversing the momentum that RPM has gained this year. CMS still has work to do in order to clarify how and when each code should be billed. For example, the inconsistencies in language in relation to what can constitute “interactive communication” time in 99457, and whether 99457 and 99091 can be billed together, remain unsustainable. With that being said, the fact that these conversations are being had remains true to the overall trend of widening access to RPM. While 2020 may have been the catalyst that RPM needed to overcome logistical and legal barriers, 2021 looks to be the year that solidifies its expansion.