RPM-What CMS has in store for 2021

2019 saw the advent of RPM codes 99453, 99454 and 99457.  These were the foundation for reimbursement for the set-up of RPM technology and services and the subsequent patient-provider interaction in the context of the patient generated data.  Although 99457 covered the initial 20 minutes of patient interaction it was insufficient and therefore code 99458 was instituted in 2020 to cover each additional 20 minutes of patient-provider interaction.  To build on these codes for 2021 CMS is proposing a few clarifications:

  1. Following the Public Health Emergency for the COVID-19 pandemic CMS will require:
    • that an established patient-physician relationship be present to utilize RPM services and
    • 16 days of data for each 30 days must be collected and transmitted to meet codes 99453 and 99454. CMS will subsequently decide whether this amount of data will be sufficient.
  2. CMS will require consent be obtained for RPM at the time the service is being rendered.
  3. Auxiliary personnel, defined as any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician, will be allowed to furnish CPT code 99453 and 99454 under the physician’s supervision.
  4. The medical devices being supplied to the patient as part of code 99454 will have to be reliable and valid and the data must be electronically collected. Manual, self-reporting of data will not be permissible. The device* also must meet the guidelines of section 201(h) of the Food Federal Drug and Cosmetic act.
  5. CMS will consider whether RPM is an E/M service. Further guidance will also be given whether physicians or NPP’s (Non-Physician Providers – physician assistants or nurse practitioners) are the only providers capable of billing for RPM.
  6. Guidance will be given as to whether RPM can be used for acute as well as chronic conditions.
  7. CMS will decide whether the patient-provider interaction involved in CPT codes 99457 and 99458 is in fact a synchronous bi-directional communication that is interactive with video or other kinds of data as described by HCPCS code G2012+
  8. CMS will be receiving comment from the medical community to determine whether the current RPM codes adequately cover the clinical scenarios in today’s clinical practice.

RPM services are here to stay and will represent an integral part of clinical care.  CMS has indicated a firm commitment to the establishment and further development of RPM in clinical practice.  CMS recognizes some of the inherent challenges in adopting RPM services in routine practice and as its guidance becomes more concrete it is safe to say that we can expect an increasing adoption of RPM based technology.

  1. *The term ‘device’ does not include software functions excluded pursuant to section 520(o); that excludes software the is designed for: Helping patients (i.e., users) self-manage their disease or conditions without providing specific treatment or treatment suggestions; Automating simple tasks for healthcare providers (HCPs); Providing or facilitating supplemental care by coaching to help patients manage their health in their daily environment; Facilitating access to information related to the patients’ health conditions or treatments (beyond providing an electronic “copy” of a medical reference); Allowing patients to communicate with their HCPs by supplementing or augmenting data or information by capturing a image for patients to send to their HCPs about potential medical conditions; Performing simple calculations otherwise normally used in a clinical practice.
  2. +In its Final Rule for the 2019 Medicare Physician Fee Schedule, CMS introduced a new code, HCPCS G2012, allowing physicians and other qualified healthcare professionals (“QHCPs”) to be reimbursed for “virtual check-ins” with patients who aren’t sure whether or not their symptoms warrant an in-office visit.

Reference:

CMS.gov

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