RTM Reimbursement Represents a New Age for Digital Therapeutics


In 2022, Centers for Medicare and Medicaid Services (CMS) introduced five new CPT codes for Remote Therapeutic Monitoring (RTM), marking the entry of patient-reported, non-physiological data into coverage criteria. For 2023, CMS plans to further expand coverage to include a CPT code for cognitive behavioral therapy monitoring.

The advent of RTM reimbursement marks an important milestone in the budding digital therapeutics space, due primarily to the following reasons:

1) Validating efficacy of telehealth:

The issuance of RTM CPT codes represents a validation of the enduring efficacy of digital care and telehealth solutions, which began to see significant uptake during the Covid-19 public health emergency when in-person care was not a viable or safe option, beyond emergency applications.

Whereas Remote Physiological Monitoring (RPM) had been in use in various device-centered applications for some time, RTM reimbursement signifies CMS acknowledgment of the utility and benefits of patient-reported, non-physiological data specifically in respiratory and musculoskeletal (MSK) care, where patient-reported information is being increasingly incorporated as a substantial component and measure of a successful and efficient outcome.

While confusion and challenges surrounding the nuances of RTM utilization and billing remain prevalent, increasing reimbursement and the anticipated availability of expanded CMS guidance will encourage more providers to take advantage of these new CPT codes going forward.

The availability of digital enablement solutions that offer provider-prescribed digital care plans, population health management tools, patient status alerting, and various other features beyond RTM-enabling capabilities continues to grow. Strategically positioned providers who employ such digital tools will be able to easily incorporate RTM into their workflows without additional burdens on FTEs and administrators.

Moreover, it is likely that CMS will examine the efficiency and parameters of current RTM CPT codes in the coming few years. Ultimately, it is anticipated that CMS will further expand the use of reimbursable RTM beyond respiratory and MSK care and incorporate patient-reported information as a requirement for reimbursement of certain remote services. As this is a nascent space, it is safe to assume that CMS will also eventually consider whether other digital therapeutics solutions, aside from RTM, may qualify for expanded coverage.

2) Incentivizing technology-enabled, optimized, and cost-effective care:

In line with ongoing CMS efforts to encourage optimized care to reduce the overall healthcare cost burden, RTM CPT codes demonstrate a continued regulatory push toward adoption of enabling technologies that optimize care and reduce costs.

By moving the majority of patient treatment outside the clinic and leveraging the home, RTM reimbursement can alleviate workflow and record-keeping burdens for providers and care teams. This makes care more efficient while supporting outcomes through high visibility into patient progress. Having more time for in-person care also enables providers to target interventions for patients who need it most, elevating care outcomes across all patients.

This also allows care teams to scale FTE resources—a particularly opportune advantage as health systems across the country continue to struggle with staffing challenges and burnout.

In addition, beyond representing a potentially lucrative new revenue source for providers—whose payments continue to decline as CMS narrows value-based payment (VBP) margins—it will also incentivize non-operative/conservative care as patient diagnoses will be increasingly managed on a global-episode basis.

3) Reducing barriers to care and encouraging shared decision making:

For rural, elderly, or low-income patients, in-person care visits incur substantial costs and challenges beyond the cost of care alone. The cost of commuting, acquiring support from family, securing time from work, or obtaining childcare can be prohibitive for many patient populations.

With a relatively small copay for RTM services, patients can mitigate the need for multiple in-person visits, enabling sizable cost and time savings over the course of a treatment plan and facilitating cost-effective care for a larger subset of patients.

Furthermore, given that RTM requires continued patient engagement with the prescribed treatment plan, providers will look to work with patients to ensure they are sufficiently informed, and that patient expectations and goals are based on a shared decision-making process. This allows providers to encourage high patient engagement and realistic goal setting, now a prerequisite for reimbursement and patient satisfaction.

With all this said, RTM cannot succeed in a vacuum. To ensure high engagement, strong outcomes, consistent reimbursement, and heightened patient satisfaction while maintaining care efficiency, reducing costs, and avoiding undue burdens on FTEs, providers will have to employ full-suite digital tools that automate RTM processes and integrate seamlessly into existing workflows and interoperability initiatives.

As CMS provides additional guidance surrounding the nuances of RTM, and as digital stakeholders develop and provide more efficient RTM automation features, awareness of the benefits of RTM will spur uptake. Going forward, it will be important to closely monitor regulatory and payor developments surrounding RTM coverage to ensure continued long-term adherence and consistent reimbursement.

Photo: Andrey Tolkachev, Getty Images

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