The 2024 Proposed Medicare Physician Fee Schedule: Impact on Remote-Patient Monitoring
A brief review of the PFS and impact on RPM companies
Ah, one of my favorite days of the year. It is a balmy, tropical heat kinda day here in Washington, D.C., but not even the weather can get in the way of the excitement associated with the release of the Medicare physician fee schedule proposed rule and comment solicitation. There is nothing that gets me on the edge of my seat quite like this one.
This article is meant to be a quick “net-net” about the rule and how it might impact your RPM program, your portfolio companies with RPM exposure, and anyone else that is following closely. There may be a bit of prognostication as well.
First, and foremost, if you just want to read to this point and no further, I think the good news is that no major news is ultimately good news here for RPM and RTM. There were very minor changes, clarifications, and additions to the RPM and RTM code families in the fee schedule. The big wins are that CMS will allow for payment to FQHCs and rural health clinics (RHCs) and has continued to expand the RTM frameworks into behavioral health (i.e., congrats to all you (1000s of you) automated CBT applications may the odds be ever in your favor).
The unbundling of RPM/RTM from the surgical global payments is a huge win for programs and companies focused on the postoperative complications reduction market. The neutral impacts are the reaffirmation of the fairly arbitrary 16 days of data each 30 days rule. This has been in effect since the end of the PHE anyways and was always going to come back, but 16 days each 30 days vs 8 days is really clinically arbitrary and is likely a utilization management approach rather than a basis from clinical evidence. CMS is also requesting comments to learn more about how RPM and RTM are delivered, which is an opportunity to try and push for some commonsense and evidence-based changes to policy in this area!
More details about the specifics can be found, below!
RPM New Vs Established Patients
This is a good rule. It is not as disruptive as many people like to comment. Patients must have a physician visit that establishes the patient as an existing patient via a full-workup and medical history process. This allows for the responsible prescription of RPM, RTM, and CCM services. In order to ensure the longevity of this code family, we must ensure proper and responsible usage. Remember the services must be medically necessary and reasonable as a test. That cannot be known without a reasonable evaluation of the patient’s conditions and ability to manage them.
In the CY 2021 PFS final rule (85 FR 84542-6), we established that, when the PHE for COVID-19 ends, we again will require that RPM services be furnished only to an established patient. Patients who received initial remote monitoring services during PHE are considered established patients for purposes of the new patient requirements that are effective after the last day of the PHE for COVID-19.
The 16-Day Requirement
This 16 days thing is an arbitrary number that was created as a part of the code creation process. The 16 days each 30 days (essentially every other day) is clinically arbitrary and serves to prevent reimbursement in many cases where patients may only transmit 8 days or 6 days. Either a sliding scale of value (50% of reimbursement for 8 days) or a reduction to around 8 days (twice a week) per month would likely be equally as effective as an alternative to this rule—it would cost more money, but we really should focus on the ROI from an investment in these types of proactive care programs and not the comparatively minimal costs of ensuring they have the cash flow to run them. This is not a surprising reaffirmation and should not come as a shock to people who have been compliant. If you or someone you know has been sticking to the 2-day PHE rule after the end of the PHE, kindly ask them to stop or they will ruin this for the rest of us who want to be responsible and see this space grow and blossom.
As discussed in our CY 2021 final rule, we are not extending beyond the end of the PHE the interim policy to permit billing for remote monitoring codes, which require data collection for at least 16 days in a 30- day period, when less than 16 of days data are collected within a given 30-day period. (85 FR 84542 through 84546). As of the end of the PHE, the 16-day monitoring requirement 147 was reinstated. Monitoring must occur over at least 16 days of a 30-day period. We are proposing to clarify that the data collection minimums apply to existing RPM and RTM code families for CY 2024.
Concurrent Billing with other Code Families (e.g., Chronic Care Management, Principle Care Management)
This was established a few years ago and is a big win for the connected care space. RPM/RTM and CCM services are highly complementary and provide sufficient funding to support programs in becoming more proactive in pursuit of better patient outcomes from high-impact chronic conditions. With combination programs, there is enough reimbursement to build our robust, high-touch care processes which are most effective when combined with RPM data collection. Read more about the evidence for this here!
Practitioners may bill RPM or RTM, but not both RPM and RTM, concurrently with the following care management services: CCM/TCM/BHI, PCM, and CPM. These various codes, which describe other care management services, may be billed with RPM or RTM, for the same patient, if the time or effort is not counted twice.
Unbundling from the Surgical Global Periods
This is a HUGE Win. Currently, the belief is that you cannot bill for RPM/RTM services under the bundled payments for certain procedures such as joint replacements. There is a major clinical opportunity here and this unbundling will encourage surgical practices and ASCs to adopt these proactive, readmission and complication reduction programs using technologies to monitor patients post-op.
We are proposing to clarify that, in circumstances where an individual beneficiary may receive a procedure or surgery, and related services, which are covered under a payment for a global period, RPM services or RTM services (but not both RPM and RTM services concurrently) may 150 be furnished separately to the beneficiary, and the practitioner would receive payment for the RTM or RPM services, separate from the global service payment, so long as other requirements for the global service and any other service during the global period are met.
Allowing Reimbursement to Rural Health Clinics and FQHCs
CMS proposes allowing federally-qualified health centers (FQHCs) and rural health clinics to bill for RPM/RTM services under a similar framework to chronic care management services which are already allowed. This makes sense. FQHCs often care for patient populations with hypertension, diabetes, and other chronic conditions at high rates so it makes sense to bring these technologies with proven outcomes into those settings. There have also been some bad rumors floating around the policy circles about how RPM can “exacerbate disparities”—which is just a massive logical fallacy and a failure to understand the evidence, but this is a step towards ensuring equitable access to these care models and technologies.
Upon further review and in line with our thinking about non-face-to-face services previously, we are proposing to include the CPT codes that are associated with the suite of services that comprise RPM and RTM in the general care management HCPCS code G0511 when these services are furnished by RHCs and FQHCs since the requirements for RPM and RTM services are similar to the non-face-to-face requirements for the general care management services furnished in RHCs and FQHCs.
For us at Avenue Health, this is a big deal as we operate a significant hypertension RPM program at an FQHC in Alabama. For anyone who supports FQHCs, this is a win in terms of revenue opportunities for clinics and thus the sustainability of the programs that were grant funded by HRSA during the pandemic.
One Practitioner Can Bill and Only for One Device
This is a complicated issue. CMS indicates that they will also use RPM and RTM services for attribution for value-based payment models such as the MSSP. This really encourages adoption in primary care settings, but this rule is very difficult for companies and clinics to enforce as they do not have visibility into services that patients may already be receiving from other practices or specialists. There is no guidance on how this is to be adjudicated and who has the right to do this type of service first. Similarly, it may make sense for a nephrologist to monitor and bill for RPM at the same time as a PCP. It may make sense for an oncologist to monitor the patient’s heart while on chemo and for the PCP to monitor the patient for diabetes. Diseases do not occur in a vacuum and clinical care is still very fragmented by condition. Why would we do this if we don’t say that the patient cannot have an office visit with an oncologist in the same month as their PCP? That is the same logic as being used here—bad logic.
One device per billing episode makes sense in order to manage utilization, but it does ignore the prevalence of co-morbidities. If we believe the RPM has a high return on investment via the prevention of ED visits and hospitalizations, then we should be able to fund the provision of multiple devices for patients with diabetes and hypertension, or CHF and diabetes. Patients with multiple comorbidities also cost more on average, so the opportunity for better outcomes and less hospitalization cost makes the provision of more devices attractive here.
We reiterate our analysis described in the CY 2021 PFS final rule, in which we explained that CPT code descriptor language suggests that, even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected (85 FR 84545). We refer readers to our CY 2021 PFS final rule (85 FR 84545) for additional background.
Conclusions
I think this is a very positive proposed rule. While there are no huge wins, there are also no huge losses, so I am very content with this release. There is also a great deal of evidence in this document that CMS is paying close attention to these codes and their impact, so there is a huge opportunity for the industry to ensure we share positive outcomes and clearly discuss the impact of these programs on Medicare beneficiaries. The expansion of the coverage to post-operative global payments and FQHCs is indicative of Medicare’s recognition that these services offer important functions. This is an opportunity to get organized and respond to the request for comments outlined in the document. Ultimately, we have the evidence to convince CMS of both the clinical- and cost-effectiveness of many connected care programs that leverage digital technologies to enhance the provision of healthcare services.