Remote Therapeutic Monitoring (“RTM”) uses digital technologies to gather therapeutic adherence and/or therapeutic response data from patients in one location and transmit that information to healthcare providers in another location for analysis. CareTuner utilizes RTM services to facilitate a more customized approach to migraine management through the CareTuner platform and patient applications. These services help improve treatment and care management for patients suffering from chronic neurological conditions, thus enhancing patients’ quality of life and reducing hospitalizations, readmission rates, medication wastage and the overall cost of care.

RTM Codes

The descriptors for the 2023 RTM codes are as follows:

CPT code 98975: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); initial set-up and patient education on use of equipment

CPT code 98976: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days

CPT code 98977: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days

CPT code 98978: Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavioral therapy, each 30 days

CPT code 98980: Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes

CPT code 98981: Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes

General Frequently Asked Questions

• Are there patient co-pays for these virtual care management services?

  Yes. As with all Medicare services, patients are responsible for all applicable co-payments and cost-sharing amounts. Medicare Part B beneficiaries are typically responsible for a 20% co-pay each time a code is billed. During the COVID PHE, providers may opt to waive the collection of patient copays. Commercial payers may or may not, at their option, require a co-pay for these services.

• Is there a recommended billing format for the virtual care management codes?

  CareTuner providers should follow current billing practices and ensure that all the requirements for each code are met, such as documenting medical necessity for offering these services and patient consent in the medical record. There is no requirement for submitting additional documentation along with a claim.

• How can I find the most up-to-date reimbursement amounts for virtual care management

  services?

  You can find can confirm current Medicare reimbursement amounts by searching for the relevant CPT code at https://www.cms.gov/medicare/physician-fee-schedule/search/overview. Reimbursement by commercial payers may vary by payer and geography. Please confirm with each of your contracted payers.

• What constitutes “clinical staff” for purposes of virtual care management services?

  A clinical staff member is defined in the CPT Codebook as “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that service.” This means that the type of personnel that qualify as “clinical staff” for purposes of virtual care management varies by state law and providers should look to applicable scope of practice laws in the state where the patient is located to determine what levels of staff can and cannot provide monitoring and treatment management services for purposes of virtual care management.

• For purposes of billing virtual care management services, can the billing practitioner utilize clinical staff that are outsourced and located overseas?

No. Medicare does not pay for services provided by individuals located outside of the U.S. and its major territories.

RTM Frequently Asked Questions

• Which practitioners can bill Medicare directly for RTM services?

  Providers who are eligible to bill Medicare directly for their services and whose scope of practice includes RTM services are eligible to bill for RTM services. In all cases, practitioners must practice in accordance with applicable state law and scope of practice laws.

  Practitioners may include:

  • Physicians
  • Anesthesiology Assistants
  • Certified Nurse Midwives
  • Certified Registered Nurse Anesthetists
  • Clinical Nurse Specialists, Clinical Social Workers
  • Nurse Practitioners
  • Occupational Therapists in Private Practice*
  • Physical Therapists in Private Practice*
  • Physician Assistants
  • Psychologists
  • Qualified Audiologists
  • Speech Language Pathologists in Private Practice**RTM treatment management services (CPT codes 98980 and 98981) can be furnished by therapists who are working in rehabilitation agencies and CORFs, but not when a patient is inpatient in a hospital or SNF.

• What types of devices can be used for providing RTM services?

  CPT codes 98976 and 98977, billed for the ongoing supply of RTM devices, provide reimbursement for devices that monitor the respiratory (98976) or musculoskeletal (98977) system. In the 2023 Medicare Physician Fee Schedule (“2023 MPFS”) Final Rule released November 1, 2022, CMS added a new code for the supply of RTM devices for Cognitive Behavioral Therapy (98978), but CMS has not assigned a specific valuation to this new code.

  For both RTM and RPM services, the CPT Manual states that devices used must be “medical devices” as that term is defined by the U.S. Food and Drug Administration (“FDA”) in the Food, Drug & Cosmetics Act (“FD&C Act”). This does NOT mean that a device used must necessarily go through the FDA “clearance” or “approval” process for reimbursement purposes, but the FDA may require this depending on the device’s status under applicable FDA pathways. Importantly,

  the FDA’s definition of a “medical device” includes certain software functions which are included in the CareTuner software platform. More information regarding medical devices under the FD&C Act can be found on the FDA website.

• Does RTM require a certain number of readings?

  Yes. Although the 2022 Medicare Physician Fee Schedule is silent on the matter, the CPT Manual states that the RTM device codes (CPT codes 98975, 98976, and 98977) should not be reported if monitoring is less than 16 days. Please note that CMS and auditors generally defer to language in the CPT Manual when the Rule is silent. To date, there is no specific prohibition, however, on billing the treatment management services codes (CPT codes 98980 and 98981) if less than 16 days of transmissions have occurred as long as the required 20 minutes of time has been accrued and all other billing requirements are met.

• Did CMS designate RTM as “Care Management Services” like they did with RPM, allowing the use of clinical staff to provide these services under general supervision?

  While CMS has not explicitly designated the RTM codes as “care management services,” in the 2023 Medicare Physician Fee Schedule, CMS stated that “[a]ny RTM service may be furnished under our general supervision requirements.” This is a change in policy from when the RTM codes were first established in 2022, and it allows the use of outsourced clinical staff who are not present in the same location as the billing practitioner for treatment management services as appropriate under that practitioner’s billing guidelines. Providers do not need to be physically present in the same location as clinical staff in order to furnish services and virtual, general supervision is sufficient to maintain compliance.

• Can a billing practitioner use outsourced clinical staff in providing RTM services?

  Yes. CPT codes 98980 and 98981 allow for clinical staff members to provide RTM services under the billing practitioner’s general supervision. When a billing practitioner reports clinical staff time, the billing practitioner bills contributing clinical staff members’ time on an “incident-to” basis. In general, services provided on an incident-to basis must be performed under direct supervision of the billing practitioner, meaning the billing practitioner must be in the same physical office location as the clinical staff. However, for CPT code 98980 and 98981, CMS allows for the clinical staff member(s) to be supervised under general supervision, meaning the billing practitioner has to be available to the clinical staff if they have a question or need assistance, but does not necessarily have to be located within the same office suite. This allows for an outsourced model in which one company provides RTM services for a particular patient population via clinical staff, similar to the model commonly used for remote physiologic monitoring (“RPM”) services.

• What does “non-physiologic” mean for purposes of billing the RTM codes?

  CMS does not specifically define “physiologic” data for RPM or “non-physiologic” data for RTM, though it does reference “therapy response” and/or “therapy adherence” data, including medication response/adherence. In the 2022 Rule, CMS gives examples of health conditions where non-physiologic data can be collected, including musculoskeletal system status, respiratory system status, therapy (for example, medication) adherence, and therapy (for example, medication) response. Providers should use their professional judgment in determining what constitutes “non-physiologic” or “therapeutic” for purposes of RTM.

• Can patients self-report therapeutic data for RTM?

  Yes. RTM data can be patient self-reported or automatically transmitted through a SaaS platform that is classified by the FDA as Software as a Medical Device (“SaMD”), such as the CareTuner platform patient apps.

• Can providers use an outsourced vendor for the “supply of device(s)” and still bill the device supply codes?

  In order to bill CPT codes 98976 and 98977, the CPT manual requires providers to supply to patients the medical device that captures the recordings and/or programmed alert(s) transmission to monitor the respiratory or musculoskeletal system. If the patient is using their own medical device (“Bring Your Own Device” or “BYOD”) or obtains the medical device from another provider, the billing provider cannot bill CPT code(s) 98976 or 98977. However, if the billing provider pays a device supplier or RTM vendor for devices or apps distributed to patients on the practice’s behalf, this would still be considered “supply” of the device, and is therefore reimbursable under the device supply codes.

• When billing 98977, what are some examples of activities that constitute 16 events of data transmissions?

  There are two general categories of data that may constitute 16 events of data transmissions:

  • Subjective, self-reported patient data, including:
    • patient questionnaires
    • patient readings of their pain for the day
    • patient response to their range of motion
  • Objective, device reported dataIn general, any information or responses directly inputted by the patient via the Software will be considered “a transmission.” For example, a self-reported patient transmission can include a patient watching/completing the progressive muscle relaxation  therapy videos and the provider sees their progress in their provider dashboard. It is important to note that each transmission must be on a separate date of service (“DOS”) when attempting to meet the 16-transmission requirement. The methods of patient data transmission can vary from month to month as long as there are at least 16 unique days of data in a given billing period.

• Do automated email reminders constitute a transmission for the purposes of the 16-day requirement for 98977? What level of patient engagement is required?

  Neither CMS nor the CPT code manual have clearly defined the parameters for usage of automated email reminders to count towards the 16-day requirement. Automated reminders without any other engagement from the patient may put CareTuner at higher risk of claim denial. Upholding some degree of patient engagement and participation is essential to maintaining an effective RTM program and allows providers to have a rich set of patient data to analyze and monitor. Without patient inputs, there would be little to no data to monitor from the patient and the program would be significantly less effective. As a best practice, we recommend that the 16 transmissions contain some level of patient acknowledgement in order to be secure that the monitoring event will count towards the 16-day requirement.

• Can you bill an evaluation/management (“E/M”) code with the RTM codes on the same DOS?

  No, you cannot bill an E/M code concurrently with any of the RTM codes on the same DOS.

• Can I bill RTM services, under general supervision, incident-to PTs, OTs, and CPs?

  CMS chose to focus its changes on the supervision levels required for clinical staff involvement in an RTM program, stating “General supervision for all RTM services. Any RTM service may be furnished under our general supervision requirements.” Physicians, nurse practitioners, and physician assistants are qualified under CMS to utilize clinical staff time incident-to billing.

  However, CMS does not attempt to rectify its previously expressed concern that general supervision is not permissible for non-E/M services codes. While this change will certainly benefit Medicare practitioners eligible to bill “incident to,” this change may not supersede the existing “incident to” prohibition for services provided incident to a therapist. Interestingly, Chapter 15, Sec. 230.5 of the Medicare Benefit Policy Manual states: “Incident to a Therapist. There is no coverage for services provided incident to the services of a therapist.” It is therefore unclear how the policy change in the 2023 Final MPFS permitting general supervision for all RTM services will benefit non-physician Qualified Health Care Practitioners like physical therapists and clinical psychologists.

• Is the use of offshore staff to provide RTM services and facilitate the CareTuner program, allowed? If so, what are the parameters for use of offshore staff?

  CMS requires that Medicare contractors or subcontractors obtain written approval prior to performing system functions offshore. Medicare system functions include, but are not limited to, the transmission of electronic claims, receipt of remittance advice, or any system access to obtain beneficiary PHI and/or eligibility information. Make sure to carefully review any covered entity customer BAAs to ensure that offshore storage, handling, or processing of PHI are not

  restricted prior to use. Additionally, Medicare will not reimburse for services rendered outside of the US or US territories – even if the individual is appropriately licensed in the US.

  Even with extensive training in these areas, non-US-based agents run the risk of falling short in meeting the expectations of US-based regulatory and compliance standard. Errors made by your offshore representatives only serve to put you at further risk for liability and sanctions. As a best practice, hiring and usage of offshore clinical staff is not recommended. However, it may be permissible to utilize offshore staff for administrative or technical support. The lines between administrative, technical, and clinical tasks can blur very easily. Please note this general reference guide provided below for your review and incorporation:

  Clinical Tasks – NOT ALLOWED

  • Examples: Cannot provide patient reminders, cannot have access to or consult with patients related to their medications, no monitoring or patient data analysis, etc.

    Administrative Tasks – MAYBE/NEED SAFEGUARDS

  • Examples: Staff may be used as the initial customer service line of contact on the phone. Training and education should be centered on appropriately redirecting and transferring calls to the appropriately licensed clinical staff or provider who can handle patient data.

  • This is not risk free. Offshore staff are not properly licensed or credentialed, as required by CMS. Improperly utilizing these staff beyond their limited scope of practice puts CareTuner at risk of False Claims Act liability and increased security incident risk.

    Technical Tasks – ALLOWED TO BE SOURCED OFFSHORE

  • Examples: IT, Technical Support

  • This is low risk and offshore sourcing of technical services (e.g. troubleshooting platform access, information on how to log in or reset their password, etc.) is a common practice in the industry.

This list is non-exhaustive, but the guiding principles are consistent. The closer a task is to the patient care journey, the more likely that this task is beyond the scope of offshore staff. The closer a task is to technical services, independent of the patient care journey, the more likely that this task is within the scope of your offshore staff.