The Centers for Medicare and Medicaid Services (CMS) released the proposed Medicare physician fee schedule regulation for 2022, which includes an analysis and payment calculations for the new Remote Therapeutic Monitoring (RTM) CPT codes issued by the American Medical Association (AMA) late last year. As announced in earlier this year, these codes may enable indirect reimbursement for digital therapeutics and similar devices by identifying the physician’s (or other qualified professional) services that will be associated with utilizing the device. This may allow digital therapeutic manufacturers to offer their products to healthcare providers as a service and for the provider to get reimbursed for setup, use and management of the product.
The AMA will provide the full nomenclature for these codes later this year. They are currently listed as the following:
|Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment.|
|Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days.|
|Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days.|
|Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes.|
|Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (list separately in addition to code for primary procedure).|
It is notable that the CPT codes focus specifically on respiratory and musculoskeletal systems. It seems that the AMA and CMS are assuming a wait-and-see posture to determine which digital therapeutic products physicians will bill for and the extent of that billing, from both the work and practice expense values.
In this proposed rule, CMS is attempting to keep the payments for these new monitoring codes equivalent to those that have been used for the existing Remote Physiological Monitoring (RPM) codes, which are used primarily for diagnostic purposes. This equivalence is based on relative value units (RVUs), not purpose of the codes. Thus, for the RTM codes identifying physician time and management (989X4 and 989X5), the RVUs and resulting payment amounts will be the same as they are for the RPM codes. Likewise, for the RTM codes that do not involve provider time and management (989X1, 989X2, 989X3), the practice expense (PE) RVUs are the same values as those for the corresponding RPM codes.
CMS notes that professional billing for the two RTM codes (989X4, 989X5) may be difficult as it seeks to decouple the codes structurally (the construction of the codes, not the RVU amounts) because the provider that can bill both sets of codes is limited to physicians and other qualified healthcare professionals. Due to the current regulatory structure and the supervisory implications of evaluation and management (E/M) coding, healthcare professionals like physical therapists cannot bill using this type of code. Through its formal comment process, CMS seeks solutions to this regulatory quagmire.
While that is being worked out, we anticipate that professionals will find ways to bill each of the five codes when applicable and appropriate and can expect the payment amounts below (plus or minus geographic adjustments) based on the proposed conversion factor (or index payment amount) of $33.58.
|Code||Work RVU||PE RVU||Malpractice RVU||Total RVU||Anticipated National Payment Amount|
As we learn more about the proposed rule and review stakeholder comments, we will keep you updated on this important industry topic. Talk with one of our policy or coding experts about how your product can obtain an optimal level of reimbursement.
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Brian Abraham, Director of Revenue Management Solutions at EVERSANA™ helps medical technology and biopharma companies develop and execute strategies around coding, coverage, and payment for innovative medical technology products. He has 20 years of…
Marty is an innovator at the cross section of product development and regulatory affairs in the medical device and digital medicine sectors. In recent years, he led the effort to obtain the first ever…