Remote patient monitoring: Is a change coming for codes?

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Medical experts could soon offer guidance on the next step in the evolution of billing codes for remote patient monitoring (RPM).

This month, the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel meeting proposed agenda includes consideration of 15 codes or revised codes used for remote monitoring of patients.

Current codes used for remote monitoring of physiologic conditions were introduced in 2019. Codes followed in 2022 for remote therapeutic monitoring (RTM), which collects information about nonphysiologic data, such as pain levels and medication adherence.

The time is right for a review, according to the Bipartisan Policy Center (BPC), a nonprofit that assists federal lawmakers in drafting legislation on a range of issues. In January, the BPC published the report “The Future of Remote Patient Monitoring.”

“The percentage of patients using it is still pretty low, but it’s increasing rapidly, so that’s why we think that this is a really good time to be looking at the policies and refining them,” said coauthor Maya Sandalow, senior policy analyst for BPC.

Converting codes

Currently there are five codes for remote physiologic monitoring, six codes for RTM and three dedicated to continuous glucose monitoring. The May agenda includes six new codes and nine revisions that would allow physicians more flexibility in time spent using RPM and RTM, according to industry analysts.

The current codes require minimum times for physicians and other clinicians to collect data, analyze it and interact with patients. For example, currently, to bill for some codes, physicians must collect patient data on at least 16 days of a 30-day period or spend at least 20 minutes interacting with a patient per 30 days, Sandalow said. The codes under consideration in May would allow billing for two to 15 days of data and 11 to 20 minutes of patient consultation for RPM and RTM.

Talking to physicians, BPC heard they did not always need 20 minutes with patients, and the codes did not take into account physician time spent reviewing data, Sandalow said. There are cases in which shorter amounts of time and fewer data are clinically indicated and fine for patient care, she said.

“This is allowing more flexibility for the condition of the patient, and not every patient needs a certain amount of time,” said Daniel Tashnek, J.D., cofounder of health software company Prevounce.

Tashnek used the example of a physician and patient who work together with RPM and other treatments to control the patient’s hypertension over eight months. “Once they’re controlled, does that mean they should be out of the program? Maybe, but maybe not,” because it still could be valuable for the patient to take a blood pressure reading two or three times a week and for the doctor to review it, he said.

Adding a window of 11 to 20 minutes may not sound like much, but the time adds up—so much that the 20-minute threshold for reimbursement results in approximately 30% of care being uncompensated, said Chris Adamec, vice president of the Alliance for Connected Care, a coalition of telehealth and RPM organizations.

Questions remain

Whatever action the CPT Editorial Panel takes in May, there are at least two major unknowns.

The Medicare Physician Fee Schedule generally is published in summer; a public comment period follows and it is finalized in November, said Lucienne Ide, M.D., Ph.D., founder and CEO of Rimidi, an RPM company.

“My question is timing and lead time on any changes,” Ide said. “I would not be surprised if they move forward with these changes. I also would not be surprised if it didn’t get incorporated into the 2025 Physician Fee Schedule just because it’s a little bit of a time crunch. Six months is a long time, but it’s not.”

The draft agenda includes the codes and brief explanations but no reimbursement rates. There is a push for the codes to be paid the same regardless of time spent, but there could be a differential because spending less or more time usually translates to less or more payment, Tashnek said.

Primary care is key

However those shake out, vendors are confident primary care physicians (PCPs) probably will be responsible for the next wave of growth in RPM.

In his congressional testimony, Chris Altchek, founder and CEO of Cadence, a remote monitoring company, said his company’s experience with Medicare beneficiaries and PCPs “has made clear that RPM is key to the future of primary care.” He said his customer base is 95% primary care physicians who want to improve how they manage patients’ chronic conditions outside of office visits.

Depending on the insurance, patients may not have copays for primary care but may have copays for specialty care. If the primary care physician is directing RPM and RTM, it could be appealing to patients who would not have copays, Ide said.

For a majority of the population, the primary care doctor is the quarterback of the health care team, Ide said. Patients may see a specialist once a year or once every couple of years, but the PCP does most of the management, she said.

Tashnek agreed. Patients with major ailments may come under specialist care, but for those with hypertension and diabetes largely under control, PCPs already are guiding a lot of that management, he said.

What happened in February?

The May proposal is the second for consideration this year. In February, the CPT Editorial Panel was to consider a proposal to combine RPM and RTM for coding and billing purposes. That plan was withdrawn from consideration without explanation.

The goal of combining codes to reduce administrative burden is understandable, Sandalow said. BPC and others commented that plan to combine the codes could impede needed research on the best ways to use RPM and RTM services, she said.

In January, the Alliance for Connected Care (ACC) sent a four-page letter to members of the CPT Editorial Panel highlighting potential issues if that happened.

“We have concerns with potential consolidation of this coding because we do not believe these changes would improve a clinician’s ability to manage care and we are concerned with downstream implications of this change — such as the potential exacerbation of concerns with appropriate utilization and practice expense calculation for the relevant device codes,” said the letter from Adamec.

At that time, ACC focused on four themes:

• The need for additional input from a wider range of stakeholders using RPM and RTM.
• Keeping RPM and RTM separate due to different clinical uses, evolving technology and relative newness of RTM.
• Simplifying coding could make it harder for payers to support multiple clinicians providing clinically distinct services.
• Additional priorities such as the 20-minute threshold for reimbursement, practice expenses and using multiple medical devices for different conditions.

ACC did not get a formal reason for the withdrawal of RPM and RTM codes from consideration earlier this year.

“I can say that from what’s listed in the public agenda, it seems like they listened to a lot of the things that we said, and we really appreciate that,” Adamec said. “It seems like they have been really good partners and took our input.”

Future work

Analysis from earlier this year hints at potential future policies that physicians, regulators and lawmakers should consider for RPM and RTM.

Along with the 20-minute threshold for reimbursement, ACC said the current CPT code 99454, dealing with medical devices, does not incorporate RPM software or cellular and Wi-Fi device fees as direct practice expense inputs. Medicare incorporates software costs into direct practice expense inputs for other codes and should for RPM.

The work relative value units (RVUs) associated with codes 99457 and 99458, dealing with patient interaction to adjust treatment based on RPM data, should match the work RVUs of codes for chronic care management.

Those codes also should be billable under the Hospital Outpatient Prospective Payment System. Currently they are not, so physicians in hospital outpatient department settings cannot offer RPM to patients.

BPC had 12 recommendations centering on three aspects, generally through congressional action or rules through the relevant offices at the U.S. Department of Health and Human Services:

• Ensuring appropriate service coverage. CMS should clarify RPM and RTM policies and work with AMA to expand RTM codes. The Medicare Payment Advisory Commission should report on the effects of remote monitoring and patient cost by state.
• Improving equity by providing physicians and patients with comprehensive information on device performance.
• Ensuring data security and privacy, with appropriate standards to protect personal health information while making remote monitoring devices interoperable with electronic health records.

In March, Altchek offered his recommendations in testimony before the U.S. House Committee on Ways and Means, as follows:

• Rural patients generally have less access to primary care services, but there is geographic variation in Medicare’s reimbursement for RPM, creating a disincentive for physicians in those regions, Altchek said. For example, RPM reimbursement in rural Missouri is 33% of what it is in San Francisco and 11% below the national average, even though costs are largely the same.
• Congress should cut the 20% copay for RPM services for at least two years to study the effects on patient outcomes and Medicare spending.
• The national average Medicare reimbursement (nonfacility) for monthly recurring RPM services has dropped, ranging from 7% to 28% since 2019. That needs to be restored. “These are high-impact services for both patient outcomes and costs that should be valued accordingly,” Altchek said.