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Reimbursement Landscape for Digital Medicine Continues to Advance with CMS

The Centers for Medicare and Medicaid Services (CMS) recently announced several new payment and coding proposals that, once finalized, would recognize and advance the use of digital diagnostic and therapeutic modalities. In this week’s update, we provide information on the new payment rules the CMS proposed for Calendar Year 2023. In our next update, we will provide information on the upcoming meeting of the American Medical Association’s (AMA’s) CPT (Current Procedural Terminology) Editorial Panel.

On July 26, CMS published its annual proposed rule on the Medicare Physician Fee Schedule (PFS), which provides payment updates for professional services rendered to Medicare patients. Over the past few years, CMS has implemented payment rates for newly released CPT codes related to Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) of patients who are prescribed the use of digital devices to report biomarker, anatomic, or metabolic data points.

CMS currently pays for RPM such as blood glucose monitoring when patients are prescribed these devices by their physicians. On the RTM side, CMS pays for CPT codes related to monitoring of respiratory and musculoskeletal systems.

For 2023, CMS is proposing to pay for RTM services for cognitive behavioral therapy through digital devices, based on a CPT code the AMA still is developing (i.e., the code has not yet been issued). Because of the wide range of digital therapeutic devices that focus on psychiatric conditions and behavior change, CMS did not propose a payment amount and instead proposed that this to-be-named CPT code be “contractor-priced,” meaning that Medicare Administrative Contractors (MACs) will set the payment amount based on the costs associated with the monitoring and the devices. In practice, when one of these devices is prescribed and issued, the clinician will need to provide documentation of the price (e.g., the invoice), as well as documentation of medical necessity to receive reimbursement commensurate with the cost.

Through the proposed rule, CMS also follows up on an issue discussed in the 2022 PFS rule regarding physical and occupational therapies for which RTM applies. Statutory limitations restrict Medicare payment for certain services to physical therapists (PTs) and occupational therapists (OTs), thus the payment rules would not have allowed for direct payment of RTM services to these practitioners. CMS has now created Medicare-specific HCPCS codes for these types of services so that PTs and OTs can receive the RTM payments for the digital therapeutics that they provide to patients who receive them under an approved plan of care. Each of the codes describes whether a physician or a non-physician provides the assessment and communication services during the period of care (with billing limited to once per month). The new codes and proposed payment amounts are listed below. Payment for these codes will replace the payment for the previous RTM assessment services codes.

CPT/ HCPCS CodeDescription2022 Medicare Physician Fee Schedule (Non-Facility)Proposed for 2023 (as applicable)Note
98980Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes$50.18$0.00 (but being replaced by GRTM1)Resolves statutory conflict
98981Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)$40.84$0.00 (but being replaced by GRTM2)Resolves statutory conflict
989X6PROPOSED: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavior therapy, each 30 days)N/AContractor Priced (meaning MACs will determine based on invoice)For cognitive and behavior digital tools
GRTM1PROPOSED: Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes of evaluation and management services)N/A$47.63Resolves statutory conflict
GRTM2PROPOSED: Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver over a calendar month; each additional 20 minutes of evaluation and management services during the calendar month (List separately in addition to code for primary procedure)N/A$38.37Resolves statutory conflict
GRTM3PROPOSED: Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month)N/A$29.44Includes non-physician practitioners
GRTM4PROPOSED: Remote therapeutic monitoring treatment assessment services, additional 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month (List separately in addition to code for primary procedure)N/A$29.11Includes non-physician practitioners

 

With the addition of the new codes CMS proposed, as well as their associated payment amounts, CMS continues to demonstrate its understanding of the need to recognize digital therapeutics as an integral modality of patient care. As digital therapeutics become more prevalent in the ongoing care of patients, EVERSANA is ready to assist digital therapeutics developers and manufacturers to ensure the appropriate market assessment, recommendations, and implementation of these technologies in the marketplace.

Author
Brian Abraham
Senior Director,​ Market Access & Patient Services

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…

Martin Culjat, PhD
Senior Vice President, Regulatory Innovation and Digital Medicine

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 breakthrough…