New CMS CPT Codes Put Emphasis on Remote Therapeutic Monitoring
By Matt Phillion
New CMS CPT® codes are a game changer, making remote care reimbursable and opening the door to making at-home care more accessible to underserved populations.
With nearly half of adults in the U.S. affected by musculoskeletal conditions, improved reimbursement will help expand care to patients in need, especially those faced with compounding effects of chronic pain such as depression and inactivity, as well as comorbidities like cardiovascular disease, diabetes, or obesity. Improved at-home care for these patients will help them recover after surgery, while remote therapeutic monitoring (RTM) will be a pathway for providers to track individuals and adapt to their evolving needs by monitoring social determinants of health, clinical status, and more.
“On a high level, what this means is that there is an increased focus and acceptance of the fact that patient care is moving to the home,” says Bronwyn Spira, founder and CEO of Force Therapeutics.
CMS tends to incentivize the behavior they’re looking to foster, Spira explains. Thus, with these new codes, they’re encouraging providers to manage patients in the home and to do so in a responsible, metrics-driven way.
“They want to create incentives that [ensure] care in the home is being monitored safely using the right patient inputs,” says Spira. “That’s the 5,000-foot overview. But getting to the brass tacks of it all, it means if you’re a provider and you’ve enabled your patient to be successful with technology at home, you can now be reimbursed for the time you spend communicating with the patient and monitoring how they are doing.”
Did the rapid move to remote care during the pandemic influence this shift by CMS? Yes and no, Spira says. “There was an increasing awareness before the pandemic that the way the U.S. health system delivers care is very expensive and not very outcomes-focused,” she says.
Pre-pandemic, we had already started to see a move to value-based, outcomes-driven care. “What changed during the pandemic was that, despite all the naysayers who said that’s not how we do it or it’s impossible or that patients and providers won’t make the switch, what we saw was actually the opposite,” says Spira. “Patients embraced being able to get care from the safety of their homes, and clinicians started to get comfortable with technology as a means to provide care in the absence of in-person alternatives. With the right tools and technology in place, the benefits of digital connections became broadly accepted and furthermore helped overcome some of the health equity and access barriers that are so prevalent in our society.”
Certainly, the argument that patients wouldn’t want to engage with health technologies has been disproven over the past few years. “They not only engaged with the technology, they enjoyed it and leaned into it so much that they don’t want to go back to in-person care when they have a reasonable, well-monitored substitute,” says Spira.
During the pandemic, emergency regulations allowed for telehealth to be reimbursed in parity with in-person care, which gave patients a way to connect with providers safely.
“But telehealth isn’t enough, and there’s a lot more that can be done,” says Spira. “There’s more value that patients, payers, and health systems at large can benefit from that goes beyond just a virtual conversation: How are you living your life? How are you managing to go to work every day? How are you dealing with your pain at night? How much medication do you need to get through your daily activities? Those are questions you won’t get an answer to in a single telehealth visit. Telehealth is a good start, but it isn’t everything.”
Questions also emerged as to whether providers would still be paid for telehealth visits when the pandemic ended. Without answers to those questions, providers questioned how deeply they should invest in telehealth infrastructure.
“So CMS leaned into remote therapeutic monitoring as a concept that goes beyond a telehealth visit,” Spira says. “Remote care is more about managing the patient in the home, and telehealth is about simply replacing an in-person visit with a virtual one. That was really forward-thinking of CMS in my opinion. They are essentially asking: We can do this via a video conference, but is there more we can do to support at-home recovery? Can we set up reliable frameworks where providers are incentivized for virtual care and remote monitoring?”
One of the challenges of providing episodic at-home care, Spira explains, is keeping tabs on a patient longitudinally over time. There’s a litany of things that make ongoing monitoring via in-person visits difficult: getting time off from work, finding childcare, access to transportation, etc. “All to see a doctor for five minutes. There’s a lot of issues with access to in-person care that can and should be overcome with remote monitoring,” says Spira.
The other piece to this, she says, is the equity question. Technology can be leveraged to alleviate challenges in healthcare deserts or overcome education or language disparities. “There are a lot of places where technology can be useful in battling inequities,” says Spira.
The data component
The CPT codes for monitoring patients remotely have a baseline requirement for patient engagement. For providers to bill these codes, the patient needs to be actively adhering to their treatment plan and achieving positive outcomes.
The RTM codes reinforce the behavior of providers who are already spending time monitoring their patients remotely. Spira points out that providers usually want to do the right thing for their patients regardless of reimbursement, but the new codes help validate that these actions are a worthwhile investment of time and energy and could become the new standard of care.
On the other hand, the technology industry often is focused on reimbursement, which will open the door for new tech going forward—and validate the work of organizations that were ahead of the curve and deployed technologies for remote monitoring years before the RTM codes were released.
A leap forward in recovery
Beyond billing and data, what does the advent of remote monitoring mean overall for patient care? “I think we’re going to see a huge improvement in patient outcomes,” says Spira. “We now have telescopic vision into the home, and this allows providers to be much more proactive.”
Providers will be able to intervene to prevent adverse events like complications before they become a costly readmission and will have opportunities to preemptively educate patients before problems occur at home.
“It’s going to have a huge impact on both patient outcomes and costs, because of the ability to control recovery at home without requiring the patient to come back to the hospital,” says Spira. “When you see the patient in the clinic, it’s a tiny window into their lives, not the full panoramic view into how they actually live. But when we capture holistic, contextual data, it becomes much more meaningful, measurable, and even predictive.”
Remote monitoring reduces the time between appointments when things can take a turn for the worse, which is also when patients are most vulnerable—missing information, anxious, and often alone. There is so much opportunity for real-time intervention with daily visibility.
The ability to help patients expands not just horizontally but vertically as well, Spira says. “I think we’re going to see technology going deeper into different healthcare verticals, and also span longitudinally over a condition so it’s not just episode-based,” says Spira. “Going forward it’s going to be more about that early engagement, the whole life cycle of that diagnosis instead of just popping in and out of the patient’s life.”
There are some hurdles to anticipate, naturally: Many providers still lack a broad understanding of the RTM reimbursement codes themselves and how to deploy them. Some may be a bit skeptical at first until they get more regulatory clarity.
Many organizations are still digging out of pandemic-related challenges such as staffing shortages, revenue shortfalls, and canceled elective surgeries, and they may not be ready to flex their technology-buying muscles. But if history is any indicator of how this will play out, CMS has a pattern of suggesting, then mandating, then penalizing for regulatory changes.
“My sense is that if you don’t consider it now, down the line you may regret it,” says Spira. “Once CMS has made a decision to go in a certain direction, that’s the process they follow. Given the positive outcomes for both patients and providers, I think we will see many organizations move in this direction.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.