Our Response to the Updated RTM Codes from CMS
Medication nonadherence — not taking medication as prescribed — costs our health system more than $500B per year in preventable morbidity and mortality. The reasons for nonadherence are multifaceted and varied, and without providing medical support between clinical visits, the healthcare system misses opportunities to help patients overcome the social determinants of health that contribute to their medication adherence challenges.
As of January 2022, the Centers for Medicare & Medicaid Services (CMS) has opened up a path to solving the medication nonadherence problem by introducing a set of Current Procedural Terminology (CPT) codes that allow healthcare providers to be reimbursed for Remote Therapeutic Monitoring (RTM).
Since the adoption of the first set of RTM codes, healthcare providers have had the option to use RTM programs, like emocha Health’s digital medication adherence solution, to bring care to patients outside the confines of clinical settings. emocha’s video Directly Observed Therapy (DOT) program scales the gold standard for medication adherence, DOT, by pairing frequent, asynchronous video messaging with human engagement to transform medication adherence challenges into medication engagement opportunities.
However, RTM’s adoption across the healthcare industry has been lackluster as the RTM codes do not allow providers to count time spent by clinical staff towards billing due to the direct supervision requirements for RTM CPT codes 98980 and 98981. Furthermore, coverage is limited to musculoskeletal and respiratory conditions.
In July, CMS took a step to improve RTM by recommending significant changes in the 2023 proposed Medicare Physician Fee Schedule. On September 6, we submitted our comments on the proposed rule.
One of the most significant changes relates to who can perform the monitoring of data submitted by patients. To date, time spent by the clinical staff of a billing provider can only be counted towards RTM if the staff is in the building (direct supervision). CMS is proposing to replace RTM CPT codes 98980 and 98981 with HCPCS codes GRTM1 and GRTM2 which will also be categorized as “care management” services to allow for general supervision of auxiliary staff who provide services incident to the billing practitioner. This means that the clinical staff of the billing provider can work remotely. This opens up the opportunity for virtual care providers such as emocha to augment provider clinical teams. We applaud this update as a step towards expanding virtual care services for Medicare patients.
But despite these improvements, the proposed updates do not address all of the major limitations on how providers can use RTM.
As part of our comments to CMS, we prioritized the following suggestions that will increase clarity and flexibility for RTM services:
- To create an additional condition/system/disease agnostic device code for RTM to benefit patients with all chronic and acute conditions. We applaud the proposed expansion of RTM to Cognitive Behavior Therapy Monitoring (CBT) and urge CMS to further expand RTM use by creating a device supply code that could be used for patients with all chronic and acute conditions, particularly those that rely on monitoring medication adherence and therapeutic response to keep patients healthy, such as heart failure, hypertension, diabetes, thyroid, GI, oncology, sickle cell disease, patients with a substance use disorder, and patients with a solid organ transplant. We maintain that a disease-by-disease approach to broadening RTM makes little sense, especially since medication adherence is a problem across nearly all chronic conditions.
- To replace the 16-day requirement for the proposed GRTM codes with a requirement for at least 50% adherence to the patient’s treatment regimen and to apply this interpretation to all Remote Patient Monitoring (RPM), RTM, CPT, and HCPCS codes. Some conditions like latent tuberculosis infection and asthma, for example, do not require medication monitoring for 16 days per month. Utilizing a percentage threshold, as we suggest, would allow therapeutic monitoring reimbursement for patients that may be prescribed a regimen of fewer than 16 days within a 30-day period but still require 20 minutes or more of the care team’s time.
Our other suggestions are more technical but will reduce administrative barriers to RTM adoption:
- Specify within the code descriptors for GRTM1 and GRTM2 that clinical staff time may be attributed to the 20-minute time requirement for these codes when delivered incident-to physician/non-physician practitioner (NPP) services and to include in the code descriptors that “physician/NPP professional time and/or clinical staff time” is attributable toward the required 20 minutes for both GRTM1 and GRTM2.
- Eliminate the proposed requirements that CPT codes 98975 and 98976 or 98977 must be billed before billing GRTM1-GRTM4 to allow for RTM to be used for all chronic and acute conditions.
- Adopt CPT code 989X6 for CBT since medication adherence is particularly critical to the success of CBT, and RTM can help ensure maximum efficacy.
- Allow for the concurrent billing of RPM and RTM where appropriate and allow for RPM and RTM device supply CPT codes 99453 and 99454 to be billed in conjunction with RTM device supply codes 98976 and 98977 when separate devices are provided to the patient.
- Recategorize software as a Medical Device (SaMD) and ongoing maintenance of SaMD as direct practice expenses (dPE) so that the resources needed to create and update the software that collects RTM data are available.
CMS will review comments about proposed RTM codes in the following months, and final policies will likely be published in November or December of 2022. If CMS implements our suggested improvements, the RTM codes will extend virtual care services to benefit all Medicare patients, a step towards ensuring that every patient can benefit from improved healthcare delivery efforts.
Even still, the 2022 RTM codes as they stand and the proposed changes for 2023 are paving the way for improved patient care between office visits.
With emocha, health plans can easily launch a high-performing RTM program by implementing our turnkey medication adherence solution to increase patient engagement and improve clinical outcomes in less than 90 days.
Contact us to learn more about emocha and RTM.