Navigating the Medicare Final Rule 2024: RPM and RTM Insights

The recently released 2024 Physician Fee Schedule (PFS) by the Centers for Medicare & Medicaid Services (CMS) marks a pivotal moment for healthcare providers. The finalized policies, unveiled on November 2, 2023, shed light on crucial aspects of remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services within the Medicare program.

The 2024 Final Rule serves as a comprehensive guide, offering insights into the landscape of remote physiologic monitoring, commonly known as remote patient monitoring (RPM). Join us as we unravel the key takeaways that RPM and RTM providers need to navigate these transformative changes effectively.

1. RPM Will Contain an “Established Patient” Requirement

In past regulations, Medicare limited Remote Patient Monitoring (RPM) to “established patients.” Traditionally, becoming established required a new patient Evaluation and Management (E/M) session, where practitioners gather information and devise a treatment plan. The Public Health Emergency (PHE) temporarily waived this during its duration but reinstated it in May 2023. Notably, patients who received RPM during the PHE without an initial new patient exam are still deemed “established patients” per CMS, creating a grandfather clause.

Essentially, Medicare beneficiaries who began Remote Patient Monitoring (RPM) during the Public Health Emergency (PHE) will maintain their established patient standing, enjoying a grandfather clause. Conversely, individuals starting RPM services post-May 11, 2023, must undergo an initial new patient examination to meet the established patient requirement before enrolling in a Medicare RPM services program.

2. RTM Will Not Contain an “Established Patient” Requirement

Unlike Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM) services currently lack a clear-cut “established patient” prerequisite. This significant contrast, as previously highlighted, spurred stakeholders to request clarification from CMS regarding the applicability of the “established patient” requirement to both RPM and RTM. The 2024 Final Rule from CMS definitively states that, unlike RPM, RTM services do not mandate an established patient relationship after the termination of the Public Health Emergency (PHE).

Although CMS acknowledges the absence of a formal requirement, it underscores its expectation that RTM services align with an established treatment plan, likely following an initial interaction evaluation conducted by the billing practitioner. Nonetheless, practitioners should exercise caution, as forthcoming rulemaking may provide additional insights into the “reasonable and necessary” standard for RTM billing.

3. Unchanged Requirement: Collect Data for Minimum 16 Days in a 30-Day Period

In the 2024 Final Rule, CMS clarified the data collection stipulations for remote monitoring codes within a 30-day period. Notably, CMS explicitly stated that the 16-day data collection requirement does not extend to CPT codes 99457, 99458, 98980, and 98981. These specific codes, focusing on treatment management and accounting for monthly time spent, diverge from the 16-day mandate. 

This marks the first instance where CMS has unequivocally outlined in official guidance that the 16-day data collection requirement is not applicable to the treatment management codes (CPT codes 99457, 99458, 98980, and 98981) associated with Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM).

4. RPM/RTM Services Can Be Billed by Only One Practitioner

In any given 30-day timeframe, a single practitioner is authorized to submit claims for RPM (CPT codes 99453 and 99454) or RTM (CPT codes 98976, 98977, 98980, and 98981), but only if a minimum of 16 days’ data is collected on at least one medical device. CMS clarified that despite multiple medical devices being provided, billing for associated services can only occur once, by a single practitioner, per patient, per 30-day period, and only when meeting the 16-day data collection criterion.

While CMS explicitly mentioned the two codes for RTM treatment management services, future inquiries could seek clarification on whether multiple practitioners can bill CPT codes 99457 and 99458 for the same patient within the same 30-day period.

5. Billing RPM and RTM Concurrently

The rule further affirms the ability of FQHCs and RHCs to submit multiple G0511 claims per month for a single patient, as long as the essential criteria for each subcategory code are satisfied. In essence, this implies that, in theory, an FQHC could bill G0511 multiple times for all subcategory codes for the same patient within a single month. In practical terms, a provider might choose to bill G0511 up to four times for a single patient in a given month, encompassing Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and Behavioral Health integration (BHI).

In cases where a patient receives both RPM and RTM services, and multiple devices are used for monitoring, CMS affirmed the application of existing rules. These rules specify that services linked to all medical devices can only be billed

  • by a single practitioner
  • once per patient within a 30-day period
  • only when a minimum of 16 days’ data has been collected

Note: CMS has updated the rule to permit multiple G0511 billings, with a reimbursement rate decrease from $77.94 in 2023 to $72.98 in 2024. Despite the reduction, it should be considered in light of the overall positive impact on providers and patients, improving access to essential services like RPM, BHI, and CCM.

6. Remote Monitoring within Global Surgery Periods

During a global billing period for a procedure or surgery, where practitioners receive a lump payment covering post-surgical follow-up services, billing practitioners are restricted from Medicare billing for Remote Patient Monitoring (RPM) or Remote Therapeutic Monitoring (RTM) provided to the patient in that period. This restriction is due to the global billing payment covering the post-surgical follow-up services. However, this policy applies solely to billing practitioners receiving the global service payment. Practitioners not receiving this payment, such as therapists, are allowed to provide RPM or RTM services during a global period. For instance, a doctor performing surgery and a physical therapist offering RTM for post-surgery rehab and monitoring are both permissible.

CMS clarified that practitioners, under a global period, who are already providing RPM or RTM services to a patient, can continue to do so. Medicare will pay practitioners separately for these services, provided they are unrelated to the diagnosis for the global procedure and address a distinct episode of care separate from the global procedure’s episode of care. The remote monitoring services must target an underlying condition unrelated to the global procedure or service.

7. Separate RPM & RTM Reimbursement for FQHCs and RHCs

Previously, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) were not permitted to bill separately for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services. Payment was consolidated into an all-inclusive rate rather than being reimbursed separately. However, as of January 1, 2024, providers will be eligible to bill for two remote health monitoring services under the general care management code G0511, at a rate of $72.98 per patient per month. FQHCs and RHCs can provide and bill for both services to the same patient in the same month.

This is facilitated using the general care management code (HCPCS code G0511) on the respective claim forms for FQHCs or RHCs. To qualify, RPM/RTM services must be medically reasonable, meet coding requirements, and must not duplicate services already compensated under the general care management code for a given month. 

According to CMS, RHCs and FQHCs have the flexibility to bill HCPCS code G0511 multiple times in a month, as long as all stipulations are satisfied and resource costs are not duplicated. The final 2024 payment rate for HCPCS code G0511 will be published on the RHC and FQHC center websites by CMS (Check this link for FQHCs and this link for RHCs).

8. RTM Billing for Assistants under General Supervision by PTs/OTs

Physical therapists (PTs) and occupational therapists (OTs) are now allowed to furnish and bill for Remote Therapeutic Monitoring (RTM) services under Medicare. However, Medicare regulations for PTs and OTs in private practice (PTPPs and OTPPs) have traditionally mandated that all therapy services in this context be conducted by, or under the direct supervision of, the PT or OT. This direct supervision requirement has posed challenges for PTPPs and OTPPs seeking to bill for RTM services provided by assistants (PTAs and OTAs) under their supervision.

Starting January 1, 2024, a significant shift occurs, with Medicare only mandating general supervision for PTPPs and OTPPs to bill for RTM services delivered by their PTAs and OTAs. This adjustment is formalized through the introduction of an RTM-specific general supervision provision in regulatory sections 42 C.F.R. § 410.59(a)(3)(ii) and (c)(2) and 42 C.F.R. § 410.60(a)(3)(ii) and (c)(2). However, it’s crucial to note that Medicare will still require PTPPs and OTPPs to directly supervise their employed PTs and OTs if the supervised PT or OT is not individually enrolled in Medicare.

9. RPM Is Not Included in MSSP Definition

In the Proposed Rule, CMS explored the idea of incorporating RPM CPT codes 99457 and 99458 into the definition of primary care services used for beneficiary assignment in the Medicare Shared Savings Program (MSSP). However, in the Final Rule, CMS opted against this inclusion.

CMS expressed apprehension in its commentary, pointing out that while primary care providers can legitimately use RPM codes to oversee overall patient care, specialists also have the ability to bill these codes. The concern arises because only one treating practitioner can bill RPM for a particular patient. If a specialist bills these codes for managing a specific condition, the patient’s primary care provider loses the opportunity to bill RPM treatment management services for the same patient. Consequently, integrating RPM codes into the definition of primary care services for assignment purposes could improperly impact the determination of where a beneficiary predominantly receives their primary care services under MSSP rules.

How the CMS 2024 Rule Impacts FQHCs and RHCs

Increased Revenue Streams: These modifications enable FQHCs and RHCs to embrace a comprehensive approach to patient care, eliminating the need to make a choice between real-time monitoring and the enduring management of chronic conditions. The prospect of earning additional revenue streams per patient per month through diverse billing codes for CCM, RPM, and BHI serves as significant support for providers in enhancing patient care.

Enhanced Holistic Care:  Remote patient monitoring enables individuals to conveniently monitor their health from the comfort of their homes, facilitating timely interventions to prevent hospitalization and emergency room visits. These modifications also expand patients’ availability to behavioral health services, potentially enhancing the handling of conditions such as depression, anxiety, and substance use. This comprehensive care approach enables providers to cater to the holistic needs of individuals.

Moving Forward

The 2024 Final Rule signifies the ongoing development of Medicare billing guidance for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM). 

The transformative opportunities presented by the 2024 RPM reimbursement changes will significantly empower providers to deliver enhanced and accessible patient care. 
With the promise of heightened revenue and improved outcomes, FQHCs and RHCs can now realize their vision of delivering top-tier healthcare services. To discover how Netrin Health can support your journey, reach out to us for more information.