On February 28, 2023, six of the seven Medicare Administrative Contractors (MACs), who administer Medicare reimbursement on behalf of the Centers for Medicare and Medicaid Services (CMS), came together for a multijurisdictional contractor advisory committee (CAC) meeting. The purpose of the CAC meeting was to discuss remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices. Specifically, the MACs were looking to determine whether a local coverage determination (LCD) should be developed to guide those performing remote patient monitoring and utilizing these billing codes.
The public was permitted to submit written comments and responses to a set of specific discussion questions through March 10, 2023. The questions covered a range of issues including the advantages of RPM/RTM in a clinical setting and the use of third-party vendors in the provision of RPM/RTM services.
Importantly, if any MAC decides to develop an LCD after the CAC, the LCD will be published both on the MAC’s webpage and on the Medicare Coverage Database. The LCD will then go through a public comment period and other administrative hurdles before it can be finalized as policy. To date, there have been no established Medicare coverage policies for remote monitoring services.
Background on RPM and RTM Codes
The COVID-19 pandemic ushered in a new era for telehealth which, notably, coincided with the introduction of these codes. The recent expansion of remote capabilities was initially enhanced with the introduction of RPM codes back in 2018 (with reimbursement beginning in 2019). After the successful implementation of the RPM codes, CMS expanded this concept with the introduction of RTM codes in 2021 (with reimbursement beginning in 2022). These new codes helped to facilitate the overwhelming shift towards telehealth that was necessitated by the COVID-19 pandemic. Indeed, the pandemic led to a well-documented and exponential increase in the demand for, and utilization of, digital health services, including remote patient monitoring services.
While these two code families have many similarities and both apply to the general concept of remote care, there are some fundamental differences between these code sets and their intended uses. At a high level, RPM involves the collection of patient physiologic data by U.S. Food and Drug Administration (FDA)-approved, connected medical devices and analysis of such data by physicians and other “nonphysician practitioners” to develop and manage a treatment plan related to a chronic and/or acute health condition. RTM is similar to RPM but broadens the scope of data and technology to include monitoring of non-physiologic data and by other digital health technologies and platforms. The table below summarizes the key differences between these two sets of CPT codes.
The Enforcement Risks of RPM and RTM Codes
Utilization of these codes has sky-rocketed in the very brief time since their introduction. One interpretation may attribute the explosion in utilization of these codes to the legitimate and unprecedented need for, and better access to, telehealth services arising from the COVID-19 pandemic. Another, less generous interpretation may attribute the increase, at least in part, to the opportunity for fraud and abuse.
Regulatory and enforcement agencies, including CMS, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG), and the Department of Justice (DOJ) have already turned their attention towards fraudulent telemedicine schemes, resulting in criminal charges and administrative actions against dozens of providers. As regulators and enforcement agencies seek to ensure these services are provided where medically necessary and reasonable, we anticipate this scrutiny and enforcement will continue to increase apace with the expanded utilization of these services and technology.