AMA considering big expansion of remote patient monitoring CPT codes

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There's big news coming out of the American Medical Association (AMA) for practices with remote patient monitoring (RPM) programs or those considering adding programs: AMA is considering a substantial overhaul and expansion of RPM CPT codes — changes that could make it easier for practices to get paid for RPM and would further demonstrate the association's embracing of remote care management.

These possible revisions and additions are currently on the agenda for AMA's upcoming CPT Editorial Panel meeting in May. The three most significant changes AMA is considering for RPM, i.e., remote physiologic monitoring, that will be discussed at the May meeting are as follows:

• Addition of an RPM device supply CPT code that would cover 2-15 calendar days of collected and transmitted data. There is currently a single RPM device supply CPT code, CPT 99454. This code is only supposed to be used when a practice has received and recorded 16 days or more of patient data within a 30-day period. The addition of the new RPM device supply CPT code would enable practices to code for those 30-day periods where fewer than 16 but at least two readings are captured.
• Revision of CPT 99457 to include 11-20 minutes of RPM care management time. CPT 99457 currently requires at least 20 minutes of interactive communication. Revising 99457 would decrease the amount of time a practice's clinical staff must provide RPM monitoring and care management time for patient during the month to report 99457. This is particularly interesting as it would be the first care management-type service (e.g., chronic care management, principal care management) allowing less than 20 minutes to be billable.
• Revise CPT 99458 to cover each additional 10 minutes of interactive communication. CPT 99458 currently requires at least an additional 20 minutes of interactive communication. Revising 99458 would reduce the amount of additional time clinical staff spent to report the CPT code.

The AMA's public agenda does not dive into the specifics of the codes yet, and nothing is set in stone. That said, what would these coding changes look like in practice if they were approved? Let's compare the current approach to RPM coding to the current incarnation of the new rules under consideration.

Example 1: Existing hypertension program

Consider a practice with an RPM program supporting 100 patients with hypertension. During the 30-day reporting period, 50 of those patients deliver 16 or more recorded days of device data while the remaining 50 patients deliver 2-15 recorded days of device data. Under current coding rules, the practice administering the RPM program can only bill CPT 99454 for the 50 patients with 16 or more days of device readings, thus losing out on billing for those patients who failed to reach the 16-day minimum.

If the AMA proposal goes through, the practice would be able to bill for all 100 patients enrolled in its RPM program. The practice would bill CPT 99454 for the 50 patients with 16 or more recorded days of device data. It could also bill for the 50 patients with 2-15 recorded days of device data under the new CPT code. While we don't know what reimbursement rates might look like, it is safe to assume that, all else equal, more reimbursement opportunities translate to more potential practice revenue.

Hypertension patients who have been on the program for a while and have their blood pressure mostly controlled also might not require 20 minutes of RPM management time each month. Under current coding rules, these patients must either hit 20 minutes or else there is no billable service for the clinic. This often leads to patients being unenrolled when there still might be significant benefit in having them in a lower-touch program. The AMA proposal would allow for these patients to continue in the program utilizing the new 11-20 minute management code.

Example 2: New medical weight-loss program

The proposed code changes would allow RPM programs to be better targeted to conditions that do not require 16 days of measurements each 30-day period. Consider a medical weight-loss clinic that would utilize connected weight scales to monitor patients and provide care management. Under current billing, clinics generally tell patients to weigh themselves every day to ensure they hit 16 measurements even though day-to-day weight fluctuations are not material to most weight-loss patients (as opposed to heart failure and other conditions).

If the AMA proposal is implemented, the RPM code would require a minimum of 2 days of measurements to be billable. This allows the weight-loss clinic to have its patients weigh themselves weekly or every few days.

Overhaul of remote therapeutic monitoring CPT codes

It is also worth noting that AMA is considering significant changes to and expansion of its remote therapeutic monitoring (RTM) CPT codes. These potential revisions include the addition of three RTM codes to cover the reporting of respiratory, musculoskeletal, and cognitive behavioral therapy for 2-15 calendar days and a revision of CPT 98980 to include 11-20 minutes of service. The latter, like the potential revision to 99457 RPM time code under consideration, would reduce the amount of time clinical staff must engage in interactive communication with a patient/caregiver during the month for 98980 to be reportable.

If AMA proceeds with these additions and revisions, coverage changes would likely not go into effect until at least 2025. But once they go into effect, it is a safe assumption that Medicare would update its coding rules to reflect AMA's CPT changes as the federal agency typically follows AMA's coding rules. Private payers and health plans generally do not deviate from AMA's rules either, so we would expect them to update to the new codesets as well.

How these changes would affect practices

If AMA implements the changes under consideration, and Medicare follows suit, providers of RPM and RTM will have some work to do — but it's work that is likely to be financially worthwhile. First and foremost, they will need to revise how they code and bill for RPM and RTM to achieve compliance with the revised codesets and rules. The same can be said for private payers and health plans that modify their coding rules to align with any changes. Providers using software to help with revenue cycle management will need to ensure their vendor partner makes any changes to their platform to maintain compliant coding and billing.

Practices will also want to begin coding and billing for patients who report RPM or RTM services for periods of 2-15 days and for interactive communication that initial lasts at least 11 minutes and then for 10-minute additional blocks of time beyond 20 minutes of communication. These represent potential new remote care management reimbursement opportunities.

While this overhaul and expansion is only under consideration at the moment, it's clear that AMA recognizes the significant value of remote care management and wants to explore how it can further encourage practices to launch programs and help those with existing programs growth them further. Remote care management programs have already benefited numerous patients and practices. Hopefully AMA will follow through on the changes it's considering and expand those benefits.

Interested parties may register with the AMA to request access to the details of the proposal and provide official comments. You can see if you qualify as an interested party and request access here.

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.