Advancements in Reimbursement Landscape for Digital Medicine through CMS

digital medicine

The Centers for Medicare and Medicaid Services (CMS) recently announced several new payment and coding proposals that, once finalized, would recognize and advance the use of digital diagnostic and therapeutic modalities. In this week’s update, they provide information on the new payment rules the CMS proposed for Calendar Year 2023. In the nfollowing update, they will provide information on the upcoming meeting of the American Medical Association’s (AMA’s) CPT (Current Procedural Terminology) Editorial Panel.

On July 26 2022, CMS published its annual proposed rule on the Medicare Physician Fee Schedule (PFS), which provides payment updates for professional services rendered to Medicare patients. Over the past few years, CMS has implemented payment rates for newly released CPT codes related to Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) of patients who are prescribed the use of digital devices to report biomarker, anatomic, or metabolic data points.

CMS currently pays for RPM such as blood glucose monitoring when patients are prescribed these devices by their physicians. On the RTM side, CMS pays for CPT codes related to monitoring of respiratory and musculoskeletal systems.
For 2023, CMS is proposing to pay for RTM services for cognitive behavioral therapy through digital devices, based on a CPT code the AMA still is developing (i.e., the code has not yet been issued).

Because of the wide range of digital therapeutic devices that focus on psychiatric conditions and behavior change, CMS did not propose a payment amount and instead proposed that this to-be-named CPT code be “contractor-priced,” meaning that Medicare Administrative Contractors (MACs) will set the payment amount based on the costs associated with the monitoring and the devices. In practice, when one of these devices is prescribed and issued, the clinician will need to provide documentation of the price (e.g., the invoice), as well as documentation of medical necessity to receive reimbursement commensurate with the cost.

Photo by Simone van der Koelen on Unsplash