2021 Remote Patient Monitoring Changes: 10 key takeaways for practices

In December, the Centers for Medicare & Medicaid Services (CMS) released its 2021 Medicare physician fee schedule final rule. Within the final rule were some significant changes concerning remote patient/physiological monitoring (RPM) and the provision of other remote services. Practices with existing RPM programs or those thinking about launching programs in 2021 should take the time to understand these changes and ensure that their programs comply with the new rules.

Here are 10 of the most significant takeaways from the final rule.

1. Revised definition of interactive communication

In the final rule, CMS declared that for CPT codes 99457 and 99458, an "interactive communication" is defined as a conversation occurring in real time that includes synchronous, two-way interactions that can be enhanced with video or other kinds of data.

In addition to the new definition, CMS originally stated that it expected all time spent towards 99457 and 99458 to be "interactive communication." This caused quite a commotion as it meant that activities such as text messaging, care planning and general care management would no longer be countable towards RPM billing codes.

Fortunately, CMS issued a correction document on January 19 where the agency clarified that the 20 minutes of time associated with 99457 and 99458 “should include care management services and synchronous, real-time interactions.” This clarified that interactive communication contributes to the total time, but is not the only activity that should be included in the total time. The document reaffirms that at least some of the time for each code needs to be "interactive communication," but it leaves the required proportions still up in the air for future rulings.

2. Clarification concerning device requirements

The final rule clarified uncertainties surrounding the types of devices supplied to patients as part of CPT 99454. Of note, CMS stated that such devices must meet the definition of a medical device per the Food, Drug, and Cosmetic Act and electronically (i.e., automatically) collect and transmit a patient's physiologic data rather than permit patients to self-report or self-collect data.

The latter is important because it clarifies the separation between self-reported and automated RPM patient data. There have been a few new platforms in the RPM market that would have patients take pictures of their device readings or manually enter them into an app each day. This ruling makes clear that these and other mechanisms of self-recording data are no longer acceptable.

3. Reestablished patient requirement

Despite significant industry pushback, CMS finalized that it will reimplement the requirement that an established patient-physician relationship exist for the furnishing of RPM following the end of the COVID-19 public health emergency.

4. Permitted consent obtainable at time of service

CMS has finalized the rule permitting providers to obtain patient consent to receive RPM services when services are initially furnished rather than in advance.

5. Approved furnishing of services by auxiliary personnel

CMS established permanent policy that allows auxiliary personnel to furnish CPT 99453 and 99454 services under a physician's supervision. CMS has previously defined auxiliary personnel to mean "… 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."

6. Clarification of billing for services

CMS clarified that only physicians and non-physician practitioners who are eligible to furnish evaluation and management services are permitted to bill RPM services using CPT 99453, 99454, 99091, 99457, and 99458. This aspect of the requirements was already well understood.

In the correction document, the agency clarified its position that only a single practitioner can bill 99453 and 99454 during a 30-day period. This clarification runs counter to the enforcement and prior general understanding of the RPM codes and may warrant questioning the patient if they are already receiving RPM services from another practitioner during enrollment. 

7. Expanding coverage to acute conditions

CMS had initially described RPM as services rendered to patients with chronic conditions. With the final rule, it clarified that practitioners may furnish RPM services to patients with acute conditions as well.

8. Reestablishing 16 measurement-days to bill

CMS confirmed that it will maintain the existing requirement that 16 days of data for each 30- day period must be collected and transmitted to bill CPT 99453 and 99454. The 16-day requirement was confirmed despite an industry push to lower the figure, with some hoping it would drop to as few as six days.

9. Clarification on the two measurement-day waiver for suspected/diagnosed COVID patients.

One major point of confusion was the current waiver on the 16 measurement-day rule for CPT 99454 that allows billing with only two measurement-days when the patient is suspected to have or has been diagnosed with COVID-19.

A fact sheet issued by CMS concerning the final rule reiterated the current existence of this waiver and confirmed that it will expire once the public health emergency ends. However, the fact sheet and the final rule fail to mention that this requirement was established during the public health emergency and applies solely to patients who have a suspected or confirmed case of COVID-19. These omissions caused considerable confusion in the industry, going so far as to prompt several large RPM companies to inform their customers that they can bill under the two measurement-day waiver for any patient regardless of COVID-19 status.

The correction document appears to clear up the confusion. It states...

"The medically necessary services associated with all the medical devices for a single patient can be billed … only when at least 16 days of data have been collected."

While this does not specifically reference the public health emergency/COVID-19 waiver, the agency's repeated emphasis on "16 days" clearly shows that it is the current default requirement. As such, the two measurement-day waiver only applies—as the waiver itself states—to patients who have a suspected or confirmed cases of COVID-19. 

10. Approved billing CPT 99091 concurrently with newer RPM codes

Up until the 2021 final rule was released, it was widely believed that it was not permissible to bill the old (i.e., original) provider-specific CPT 99091 used for RPM at the same time as 99457, which went into effect in 2019. But the final rule seems to essentially reverse this interpretation, with CMS now permitting providers to bill for "complex" RPM management when the provider must spend significant time managing the patient and their RPM care plan.

Further, CMS noted that 99091 can be billed each 30 days whenever such complex provider management occurs without affecting the practice's ability to bill clinical staff time via CPT 99457 each calendar month.

Significant developments further defining RPM

With remote patient monitoring still somewhat in its infancy, it's not surprising to see a final rule that brings so many substantial changes to the service, including some that further enhance the value of RPM. For example, CMS's decision to expand the services covered under the 20 minutes of service delivery associated with CPT 99457 and 99458 to include "non-interactive" service time is a considerable victory for patients and providers. Particularly encouraging about the changes in the latest final rule is that CMS appears to be fully embracing RPM. Thus, we anticipate that the agency will be willing to consider and enact changes that support and encourage patient engagement and the growth of RPM programs.

Going forward, as RPM further solidifies its value and role in the delivery of care, we can expect new rules and revisions to existing rules on the federal and possibly state levels. Providers will benefit most from well-tailored RPM programs designed within the current requirements that also have the means to be flexible as requirements inevitably shift.

_{About the Author}

_{Daniel Tashnek is the co-founder of Prevounce Health, a healthcare software company that simplifies the provision of preventive medical services, chronic care management and remote patient management. Daniel is also a practicing healthcare attorney specializing in regulatory compliance, reimbursement, scope of practice, and patient care issues.}