The American Medical Association’s (AMA's) CPT Editorial Panel has removed the requirement for a patient to transmit 16 days’ worth of data for providers to bill remote physiologic monitoring codes, effective January 2026, a public document (PDF) says.
As part of that requirement, patients need to actively use a device and transmit data for at least 16 days in a 30-day period for the provider to qualify for billing. Remote patient monitoring services are billed under certain Current Procedural Terminology (CPT) codes.
The remote monitoring billing win comes as the Peterson Health Technology Institute poured cold water on RPM effectiveness for hypertension on Monday. And, in September, the Department of Health and Human Services Office of Inspector General (HHS OIG) released a report that raised alarm for potential billing fraud in remote monitoring.
An OIG representative said at the time that U.S. taxpayers "don't know what they're paying for" when it comes to RPM.
The AMA’s CPT Editorial Panel met in Washington, D.C., September 25-28 to discuss medical billing code change proposals. One of the agenda items at the meeting included a rework of the remote physiologic monitoring and remote therapeutic monitoring codes.
The panel agreed to remove the 16-day reporting requirement for the RPM device supply code, which has been a sore spot for the industry over the last several years.
There are several remote physiologic monitoring and remote therapeutic monitoring codes that providers can bill. The AMA had established payment for a provider’s time spent reviewing the patient’s data and for device setup and patient education. To bill the supply code for RPM, though, a patient needed to submit RPM data 16 days of the month, or every other day.
Getting a patient to use their connected device every other day was infeasible for many providers, who simply did not get paid for that portion of the service.
The 16-day billing threshold was too high, many argued, to receive reimbursement for the supply code. Because patients are required to take the measurements themselves, such as by stepping on a connected weight scale or by using a connected blood pressure cuff, providers could not guarantee that patients would take enough readings in a month for the providers to be paid for the services.
Providers argued that they didn’t need data for more than half the days in a month to be able to provide treatment based on remote monitoring data. For some conditions, even, reporting 16 days of data could be considered counterproductive, they argued.
The 16-day reporting requirement has been a contentious issue. In the proposed CY2024 Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) incorrectly stated that several of the RPM and RTM codes required 16-days worth of data to be billed.
More recently, the HHS OIG raised concern about remote monitoring billing; OIG specifically cited the concern that remote monitoring codes were not being billed concurrently as a “family of codes.”
“Approximately 43% of enrollees who received remote patient monitoring did not receive all three components of the monitoring, raising questions about whether the monitoring is being used as intended,” a subheading in the OIG report reads.
The OIG's assertions were contrary to CMS’ final CY2024 MPFS, that says: “We would like to offer clarification that the 16 day data collection requirement does not apply to CPT codes 99457, 99458, 98980, and 98981. These CPT codes are treatment management codes that account for time spent in a calendar month and do not require 16 days of data collection in a 30-day period.”
While there could be fraud in remote monitoring billing, RPM experts argued that the 16-days measure was not a good benchmark to determine fraud because of the issues providers have expressed with the high bar for data collection.
The new data reporting requirement change may give OIG, or other watchdogs, more insight into the potential misuse of the codes.
A host of remote monitoring companies and patient engagement solutions now assist with keeping patients engaged with their at-home devices.
For healthcare providers not using a remote monitoring service provider, patient engagement was left to existing staff or to the provider themselves, neither of which could guarantee that patients submitted enough data.
The AMA’s valuation committee, the RUC, will reconsider pricing for the codes in January 2025, according to the public summary of panel actions. In the past, coding experts have said they expect reimbursement for less than 16-days worth of data to be paid less than the existing code.