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Andrew Cass, Nick Thomas and Alan Condon – 14 hours ago

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CMS has released annual payment updates for physicians, hospital outpatient settings and the Medicare Shared Savings Program as well as a remedy for the 340B-acquired drug payment policy.

Physician fee schedule rule

1. The physician fee schedule conversion factor for 2024 is $32.74, a $1.15 (3.4%) decrease from the 2023 conversion factor of $33.89.

2. CMS is finalizing its proposal to make payment when practitioners train caregivers to support patients with certain diseases or illnesses — such as dementia — in carrying out a treatment plan. Medicare will pay for these services when furnished by a physician or non-physician practitioner or therapist as part of the patient’s individualized treatment plan or therapy plan of care. 

3. CMS is finalizing coding and payment changes it says better account for resources involved in furnishing patient-centered care involving a multidisciplinary team of clinical staff and other auxiliary personnel. The finalized services are aligned with the HHS social determinants of health action plan and help implement the White House’s Cancer Moonshot goal of every American with cancer having access to covered patient navigation services. 

4. CMS is finalizing the implementation of a separate add-on payment for HCPCS code G2211. The agency said the add-on code will “better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.” It will generally be applicable for outpatient and office visits as an additional payment, “recognizing the inherent costs involved when clinicians are the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

Hospital Outpatient Prospective Payment System and ASC rule

5. CMS finalized payment rates for hospitals and ASCs that meet applicable quality reporting requirements by 3.1%. This is a slight increase on the 2.8% payment update the agency initially proposed. 

6. This update is based on the projected hospital market basket percentage increase of 3.3%, reduced by a 0.2 percentage point for the productivity adjustment.

7. The payment updates will affect about 3,500 hospitals and 6,000 ASCs.

340B-acquired drug payment final rule

8. CMS will provide a lump sum payment to each hospital participating in the 340B Drug Pricing Program, totaling $9 billion, to make them whole from unlawful payment cuts from 2018 to 2022. The $9 billion in lump sum payments is the same in the final rule as in the proposed version.

9. About 1,700 hospitals are set to receive the funds by Jan. 1.

10. Beneficiary copayments comprise about 20% of the payments affected 340B hospitals did not receive due to the payment policy. Because of the lump sum payment structure, providers are not able to bill beneficiaries for that cost-sharing, according to the agency. CMS is accounting for beneficiary cost-sharing within the lump sum payment to 340B hospitals, which may not bill beneficiaries for coinsurance on remedy payments as a result. 

11. To implement a required $7.8 billion budget neutrality adjustment, CMS will reduce future non-drug item and service payments by adjusting the Outpatient Prospective Payment System conversion factor by -0.5% beginning in 2026. The agency said it landed at -0.5% to minimize the financial burden of this required offset on affected hospitals.

12. Providers that did not enroll in Medicare until after Jan. 1, 2018 — and thus did not fully benefit from the increased payment for non-drug items and services from 2018 through 2022 — are excluded from the prospective rate reduction.

Medicare Shared Savings Program rule

13. Changes in the shared savings program are expected to increase participation in it by between 10% and 20%.

14. Such changes include moving ACOs toward digital measurement of quality, starting Jan. 1, 2025.

15. The addition of a third step to the beneficiary assignment methodology will encourage greater recognition of the role of nurse practitioners, physician assistants and clinical nurse specialists in delivering primary care services.

16. Proposed policies will be delayed one year to align with the Merit-based Incentive Payment System to give ACOs more time to work with their participants to meet new requirements. 

Health equity

17. As part of the physician fee schedule final rule, CMS is finalizing separate coding and payment for several new services to help underserved populations. These include community health integration services, the first time physician fee schedule services specifically include such care.

18. CMS is also supporting increased dental services for people with cancer.

19. People on Medicare will also be able to access marriage and family therapists and mental health counselors.

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In this article, you’ll learn the differences and rates between RTM billing codes and RPM billing codes for 2024. CMS released the CY 2024 Physician Fee Schedule Final Rule in November 2024. The final rule includes 3,000 pages of detailed policy changes related to remote therapeutic monitoring (RTM) and remote patient monitoring (RPM) Medicare reimbursement. This article breaks down the final rule and provides key takeaways for the RTM billing codes and RPM policy updates, set to begin on January 1, 2024. 

RPM and RTM Billing Codes in 2024

Remote therapeutic monitoring (RTM) and remote patient monitoring (RPM) remote track and report on non-physiological patient data, including vital signs, medication and exercise adherence, functional status, response to therapy, and respiratory and musculoskeletal activity. Understanding the billing codes for these new remote care services can be confusing.

Remote therapeutic services allow patients to receive treatment guidance, support, and interventions outside the traditional in-office setting. These services may include counseling via video chat, text messaging programs aimed at medication adherence, virtual physical therapy sessions, and more. The goals are to increase access to care and improve outcomes.

New revenue streams opened to healthcare providers in November 2022 when the American Medical Association (AMA) created 5 CPT codes for RTM services: 98975, 98976, 98977, 98980, and 98981. The codes comprise three practice expense-only codes: 98975, 98976, and 98977, and two codes for treatment management: 98980 and 98981.

Remote patient monitoring allows providers to track vital signs, symptoms, medication adherence, and more outside of the office. This aims to detect early warning signs and prevent bigger problems. The billing codes for RPM are: 99453, 99454, 99457, 99458, and 99091.

Now that we’ve reviewed what remote therapeutic monitoring is, we will provide a quick overview of billing updates for 2024. 

RPM and RTM Billing Codes 2024

The 2024 Physician Fee Schedule Final Rule provisions clarify remote therapeutic monitoring services requirements. The codes account for the extra time needed for planning, data analysis, and interacting with patients outside of direct contact. Overall, there are a few key takeaways regarding RTM billing codes in 2024. 

Only One Provider Bills in RTM and RPM

CPT codes 99453 and 99454 and RTM billing codes 98976, 98977, 98980, and 98981 may be billed by only one clinician over a 30-day period. This is per episode of care and not per calendar month.  Therefore, if more than one provider bills for RPM or RTM services in the same month, the first provider to submit the claim will be reimbursed. The other claim (s) will be denied. 

RPM and RTM Billing Codes and Other Services 

RPM and RTM cannot be billed together during the same month. However, some services can be billed with either RPM or RTM concurrently. These are as follows:

• Chronic Care Management
• Transition Care Management
• Behavioral Health Integration
• Principal Care Management
• Chronic Pain Management

Global Surgery Period

A global period is when a physician can not bill for related office visits. However, RTM and RPM services are permitted when the billing provider of the services is not the provider who receives the global service payment. When a patient receives RTM or RPM services before a surgical procedure, CMS will pay for the RTM or RPM services outside of this global period.

FQHCs and RHCs 

The 2024 Physician Fee Schedule allows new reimbursement opportunities for FQHCs and RHCs, allowing them to receive reimbursement for RPM and RTM services. However, only one of these services can be billed under CPT code G0511. Furthermore, it can be billed multiple times each calendar month at the rate of $72.98.

The following section explains exactly what the 5 RTM billing codes cover in 2024, including the average reimbursement rate and requirements.

RTM Billing Codes and Reimbursement Rates for 2024

As of 2022, CMS adopted 5 RTM billing codes to pay for device setup, collection, interpretation, and processing of remote non-physiological data. The following section explains exactly what the 5 RTM CPT codes cover in 2024, including average reimbursement rate and requirements. These rounded numbers are based on non-facility national averages and vary by region.

98975

This code covers initial setup and patient education on the use of equipment. It can be billed once in a 30-day period when at least 16 days of data is collected on at least one medical device. The average national payment rate for CPT 98975 is $19.65.

98976

Billing CPT code 98976 pays for respiratory devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the respiratory system. The code can be used every 30 days when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98976 is $46.83.

98977

Code 98977 reimburses musculoskeletal devices supplied with daily scheduled recordings and programmed alerts and transmission for monitoring the musculoskeletal system. This can be billed once by one practitioner only when at least 16 days of data have been collected on at least one medical device. The average national payment rate for CPT code 98977 is $46.83.

98980

CPT 98980 bills for the initial 20 minutes of treatment time per calendar month. Time must include at least one interactive communication via phone or video with the patient during the month.

CPT 98980 can be billed “incident to” or under general supervision, which includes physicians, nurse practitioners (NPs), and physician assistants (PA). CPT 99457 is billed monthly. The average national payment rate for CPT 98980 is $49.78.

Notably, billing is not generally part of the Medicare benefit for qualified healthcare practitioners: physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs). Second, RTM services must be personally furnished by the billing qualified health care practitioner. When the practitioner is a PT or OT, a therapy assistant must be under the supervision of the OT or PT.

CPT 98981

In 2024, CPT 98981 covers each additional 20 minutes of treatment time per calendar month. This code has the exact requirements as CPT 98980.  The average national payment rate for CPT 98981 is $39.30.

What are the differences between RTM and RPM?

Remote patient monitoring (RPM) is different from remote therapeutic monitoring. As previously mentioned, RPM and RTM differ because RTM focuses on non-physiological monitoring. On the other hand, RPM focuses on physiological data. Providers can choose from a growing list of FDA-cleared remote patient monitoring devices and software services.

Remote patient monitoring enables the monitoring of patient vital signs outside of conventional clinical settings, such as at home or in remote areas. This telehealth service allows patients to take measurements from their homes. Once the measurement is taken, the data is sent in real-time to providers to measure physiologic data such as heart rate, weight, oxygen saturation, pulse rate, glucose levels, and more.

 Over recent years, CMS created RPM billing codes for reimbursement for digital health, which has expanded Medicare reimbursement for remote patient monitoring. This is a separate category from RTM billing codes and services. These 5 RPM CPT codes are 99453, 99454, 99457, 99458, and 99091. 

RPM and RTM Billing: 2024 RPM Key Takeaways

What are the key takeaways for medical professionals regarding RTM and RPM billing for 2024? Although future modifications to remote patient monitoring CPT codes are expected, CMS did not add the Proposed Rule RPM G codes to the final rule. CMS further establishes rates and provides yearly guidance on requirements and utilization for remote monitoring services.

As a result, these are the 3 key takeaways for RPM in 2024:

• No new RPM CPT codes appear in the final rule for 2024.
• Medicare non-facility reimbursement rates were updated for 2024
• RPM providers will continue to use CPT codes 99453, 99454, 99457, 99458, and 99091.  

RPM 2024 CPT Code Reimbursement Rates

As of 2020, CMS adopted RPM CPT codes to pay for device setup, collection, interpretation, and processing of remote physiological data. This section explains exactly what the 5 RPM CPT codes cover in 2024, including the average reimbursement rate and requirements. These rounded numbers are based on non-facility national averages and vary by region. These are different from RTM billing codes.

99453

Just as RTM billing codes cover device setup, this code pays for device set-up and patient education on the use of equipment for vital sign monitoring such as blood pressure, pulse oximetry, blood glucose, respiratory flow rate, and weight. Only one clinician bills this one-time code after the initial 16 days of monitoring in a 30-day period. The average national payment rate for CPT 99453 is $19.65.

99454

Supplying the device for daily recording or programmed alert transmissions is billed under code 99454. It may be used more than once, given that the patient uses the device at least 16 days per month. One clinician can bill CPT 99454 in a 30-day period. The average national payment rate for CPT 99454 is $48.63.

99457

This payment is for the initial 20 minutes of treatment management. An unspecified portion of that 20 minutes must involve interactive remote communication with the patient. However, how interactions must be provided is not explicitly defined. However, we assume a video call, phone call, email, and text messaging would suffice. The average national payment rate for CPT 99457 is $48.14.

Moreover, CPT 99457 is billed “incident to” under general supervision. Medicare providers can contract third-party remote patient monitoring companies to assist with RPM services. Ultimately, healthcare organizations can manage more patients and generate more revenue without significantly impacting workflows. 

99458

In 2024, CPT 99458 encompasses each additional 20 minutes of RPM services, with a maximum of 60 minutes in a calendar month. Similar to CPT 99457, documentation of how the time is distributed is required. The average national payment rate for CPT 99458 is $38.64.

99091

CPT 99091 was new in 2022 but had more requirements than the preceding codes. In 2024, it covers a minimum of 30 minutes in a calendar month for the time it takes clinical staff to gather, interpret, and process data that a patient transmits. It also covers at least one communication, which occurs by phone or email, whereby medical management or monitor advising occurs. The average national payment rate for CPT 99091 is $52.71.

Understanding RPM and RTM Billing Codes

Remote therapeutic monitoring and remote patient monitoring are two distinct categories of remote monitoring services with specific CPT codes and billing requirements. A key difference between RTM and RPM is that RTM focuses on tracking non-physiological patient data like medication adherence, while RPM follows vital signs and physiological metrics. The 2024 Physician Fee Schedule Final Rule provides clarification and billing guidance for providers offering these services starting January 1, 2024.

Importantly, RPM and RTM billing codes cannot both be used to bill for the same patient in the same month – only one clinician can submit claims. Additionally, reimbursement rates differ across the codes. As remote monitoring continues growing in healthcare, having a firm grasp of the respective CPT codes, rules for utilization, and payment rates will ensure appropriate delivery and billing of RPM and RTM services.

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The 2024 Medicare Physician Fee Schedule final rule, released by the Centers for Medicare & Medicaid Services (CMS) earlier this month, extended certain telehealth-related flexibilities that were implemented during the early days of the COVID-19 pandemic. CMS issued a Fact Sheet summarizing the telehealth updates, as well as other important Medicare policy changes.

Until 2020, Medicare reimbursed for telehealth only for patients in designated rural areas, and they were required to travel to a healthcare facility to access telehealth services. Certain federal policies that expanded telehealth access during the pandemic were set to expire at the end of 2023, but they have now been extended for another year to synchronize with other provisions that were already extended until December 31, 2024 by the Consolidated Appropriations Act, 2023.

Among the newly extended flexibilities is continuing to define “direct supervision” to permit the presence and immediate availability of a supervising practitioner through real-time audio and video communications.

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Changes to the Medicare Telehealth Services List Structure and Updates Process

Prior to the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) evaluated changes to the Medicare Telehealth Services List (the List) through an annual rulemaking process. Through this process, CMS considered whether a service met one of two criteria for permanent inclusion on the List. Category 1 services are similar to professional consultations, office visits and office psychiatry services that are currently on the List. Category 2 services are not similar to those on the List—the primary criteria CMS uses in evaluating these services are (a) whether the service is accurately described by the corresponding code when delivered via telehealth and (b) whether the use of a telecommunications system to deliver the service produces demonstrated clinical benefit to the patient. During the PHE, CMS created a third category (Category 3), which allows for temporary coverage while further evidence is developed and the service is considered for permanent (Category 1 or 2) coverage.

The current List structure and updates process have proved cumbersome and confusing to stakeholders, and so CMS finalized simplifying the List into two categories—permanent and provisional—beginning in calendar year (CY) 2024. CMS also finalized the following steps for analyzing changes to the List for the CY 2025 physician fee schedule (PFS) proposed rule:

• Step 1: Determine whether the service is separately payable under the PFS.
• Step 2: Determine whether the service is subject to the provisions of Section 1834(m) of the Social Security Act—in effect, whether at least some elements of the service, when delivered via telehealth, are a substitute for an in-person, face-to-face encounter and all of those face-to-face elements of the service are furnished using an interactive telecommunications system.
• Step 3: Review the elements of the service as described by the HCPCS code, and determine whether each of them is capable of being furnished using an interactive telecommunications system.
• Step 4: Consider whether the service elements of the requested service map to the service elements of a service on the List that has a permanent status described in previous final rulemaking.
• Step 5: Consider whether there is evidence of clinical benefit analogous to the clinical benefit of the in-person service when the patient who is located at a telehealth originating site receives a service furnished by a physician or practitioner located at a distant site using an interactive telecommunications system.

For 2024, CMS finalized its proposal to redesignate Category 1 and Category 2 codes to the new permanent category, and “temporary Category 2” and Category 3 codes to the new provisional category. CMS did not finalize any specific timeline for considering changes from provisional to permanent status—changes in status will be evaluated during the annual updates process.

Additions to the Medicare Telehealth Services List

Each year, CMS reviews requests for changes to the List. This year, CMS is finalizing as proposed a rule to add a series of health and well-being coaching services to the List on a temporary basis for CY 2024. In addition, CMS is finalizing as proposed a rule to add HCPCS code G0136, Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes, to the List on a permanent basis beginning in CY 2024. There were several other requests for additions to the List on a permanent basis, all of which were rejected by CMS in the final rule because they did not meet CMS’ current criteria, described above.

Implementing the Consolidated Appropriations Act (CAA), 2023, Telehealth Provisions

Section 4113 of the CAA, 2023, further extended PHE-related telehealth policies and required CMS to extend PHE-related telehealth flexibilities through December 31, 2024. CMS finalized its proposal to implement several provisions of the CAA, 2023, which would extend the following policies through CY 2024 on a temporary basis:

• In-Person Requirements for Mental Health Services: Delaying the in-person visit requirement for telemental health services furnished by rural health clinics (RHCs) and federally qualified health centers (FQHCs)
• Originating Site and Geographic Restrictions: Expanding the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home
• Eligible Providers: Expanding the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists and qualified audiologists (and adding marriage and family therapists (MFTs) and mental health counselors (MHCs) to the list of eligible providers)
• Audio-Only: Continuing coverage of certain audio-only telehealth services on the List

In addition, CMS finalized extending the following telehealth flexibilities through CY 2024:

• Frequency Limits: Removing frequency limitations for certain subsequent inpatient visits, subsequent nursing facility visits and critical care consultation services
• Direct Supervision of Clinical Staff: Continuing to allow for “direct supervision” to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications (pre-PHE “direct supervision” could only be met via in-person “immediate availability”) (CMS sought comment on whether to extend the flexibilities related to direct supervision and virtual presence of teaching physicians beyond CY 2024 and will consider addressing this topic in possible future rulemaking)
• Telehealth in Teaching Settings: Continuing to allow teaching physicians to have a virtual presence in all teaching settings, but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit with all parties in separate locations)
• Outpatient Therapy, Diabetes Self-Management Training and Medical Nutrition Therapy: Continuing to allow outpatient therapy (physical therapy, occupational therapy, speech-language pathology), diabetes self-management training and medical nutrition therapy to be provided via telehealth when delivered by institutional staff
• Telehealth for Opioid Treatment Providers: Allowing periodic assessments to be furnished via audio-only communications technology when video is not available, to the extent that use of audio-only communications technology is permitted under the applicable Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) requirements at the time the service is furnished and provided that all other applicable requirements are met
• Practitioner Home Address Reporting: In response to provider safety concerns expressed by public commenters regarding the expiration of provider enrollment requirement flexibilities for distant site telehealth practitioners, CMS extended the flexibility to use the practitioner’s currently enrolled location instead of their home address when providing services from their home through CY 2024 and will consider the issue further for future rulemaking.

Changes to Payment by Place of Service for Medicare Telehealth Services

When a physician or practitioner submits a claim for their professional services, including claims for telehealth services, they include a place of service (POS) code that is used to determine whether a service is paid using the facility or non-facility rate. Under the PFS, there are two payment rates for many physicians’ services: the facility rate, which applies when the service is furnished in a hospital or skilled nursing facility setting, and the non-facility rate, which applies when the service is furnished in an office or other setting. The facility rate is typically lower than the non-facility rate, but there is a separate payment to the facility (sometimes called a facility fee), in addition to the payment to the physician, to pay for facility costs (clinical staff, supplies, equipment, overhead).

CMS has evolved its guidance on the use of modifiers and POS codes for telehealth services over the past several years and during the PHE. Starting in CY 2023, CMS required that telehealth claims be billed with one of two POS indicators:

• POS “02”—Telehealth Provided Other Than in Patient’s Home
• POS “10”—Telehealth Provided in Patient’s Home

Beginning in CY 2024, CMS finalized that claims billed with POS 02 be paid at the facility rate and claims billed with POS 10 be paid at the non-facility rate. CMS explains that during the PHE, especially for behavioral health services, practice patterns evolved such that providers often see patients both in person and virtually. As a result, these practitioners continue to maintain their office presence even as a significant proportion of their practice’s utilization may be comprised of telehealth visits. As such, CMS concludes, the practice expenses for these services are more accurately reflected by the non-facility rate. Claims billed with POS 02 will be paid at the facility rate under the logic that those services will be furnished in originating sites that were typical prior to the PHE and the facility rate more accurately reflects the practice expenses of these telehealth services.

CMS noted that it will allow outpatient hospitals and other providers of physical therapy; occupational therapy; and speech-language pathology, diabetic self-management (DSMT) and medical nutrition therapy (MNT) services that remain on the Medicare Telehealth Services List for CY 2024 to bill for these services when furnished remotely in the same way they have been during the COVID-19 PHE and through the end of CY 2023, including that for hospitals, beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services.

In addition, CMS clarified that modifier “95” should be used when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by physical therapists, occupational therapists or speech-language pathologists.

Remote Physiologic and Therapeutic Monitoring

Currently, remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) codes are not stand-alone billable visits in RHCs and FQHCs. When these services are furnished incident to an RHC or FQHC visit, payment is included in the RHC’s all-inclusive rate (AIR) subject to a payment limit or per-visit payment under the FQHC prospective payment system (PPS), which is the lesser of the PPS rate or the FQHC’s actual charges. CMS finalized that starting in CY 2024, RPM and RTM services will be separately payable to RHCs and FQHCs using the general care management code, HCPCS code G0511.

In addition, CMS finalized that RTM services are allowed to be furnished under general rather than direct supervision when provided by occupational therapists (OTs) or physical therapists (PTs) in private practice. Previously, these services, when provided by an occupational or physical therapy assistant, were subject to direct supervision, which required the PT or OT to be “immediately available.” CMS sought comment on whether to allow for general supervision for a broader set of services provided by OTs and PTs and will take these comments into consideration for possible future rulemaking.

Finally, CMS confirmed and clarified the following policies related to RPM and RTM:

• RPM and RTM services can only be furnished to an established patient. Patients who received initial remote monitoring services during the PHE are considered established patients for purposes of the new patient requirements that are now effective after the last day of the COVID-19 PHE.
• 16 days of data are required within a given 30-day period for the relevant RPM and RTM codes. In response to public comments, CMS clarified that CPT codes 99457, 99458, 98980 and 98981 are exempt from this requirement, as they 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.
• RPM and RTM cannot both be billed for the same patient in the same month, though either RPM or RTM can generally be billed with other care management services as long as time or effort is not double-counted.
• RPM or RTM (but not both) can be furnished separately from services covered under payment for a global period as long as time and effort requirements are met.

Request for Information on Digital Therapies

CMS has, over time, expanded coverage for a range of digital therapies, including RPM and RTM. CMS sought information on how remote monitoring services are used in clinical practice and experience with coding and payment policies for these codes, with a focus on digital cognitive behavioral therapy (CBT).

In prior guidance, CMS indicated that digital therapeutics did not have a statutorily defined Medicare benefit category (except for certain digital therapeutics with a hardware component that met the definition of durable medical equipment (DME)), so it is notable that CMS sought comment on how it should view digital therapeutics vis-à-vis benefit category determinations.

In response to public commenters who stated that CMS has existing authority to pay for two types of digital therapeutics—those that meet the definitions of DME and those that are used incident to a physician service—CMS declined to make any changes to coverage but noted that it looks forward to reviewing forthcoming potential code recommendations from the CPT Editorial Panel meeting as part of its standard annual processes and future rulemaking.

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“This article was originally published by Foley & Lardner LLP [Centers for Medicare and Medicaid Services RPM Policies (natlawreview.com)] on [11/8/2023], and is reprinted with permission.”

On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized new policies related to remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services reimbursed under the Medicare program. 

The guidance published in the 2024 Physician Fee Schedule final rule(2024 Final Rule) addresses billing scenarios and requests for clarifications on the appropriate use of these remote monitoring codes. The 2024 Final Rule clarifies CMS’ position on how it interprets certain requirements for these services. CMS rejected some of the proposals contained in the 2024 Proposed Rule and built upon previous RPM and RTM guidance. 

Below are the key takeaways RPM and RTM providers must know about the 2024 Final Rule.

RPM and RTM Clarifications

RPM Can Only be Furnished to an “Established Patient”

In prior rulemaking, RPM services have been limited to “established patients.” Historically, in order to become an established patient for Medicare RPM purposes, a patient typically would undergo a new patient Evaluation and Management (E/M), or similar service, during which the billing practitioner collects relevant information about the patient and then establishes a treatment plan. During the Public Health Emergency (PHE), CMS waived the established patient requirement. When the PHE expired in May 2023, RPM services were once again limited to established patients. Those patients who received remote monitoring services during the PHE but who did not undergo an initial new patient exam will be deemed “established patients” under CMS’ recent rule clarification.

In sum, Medicare patients who received initial RPM services during the PHE will be considered established patients (i.e., patients who began receiving RPM services during the PHE will be “grandfathered” in). Those patients who receive initial RPM services after May 11, 2023 (the end of the PHE) will need to become an established patient before enrolling in a Medicare RPM services program.

RTM Does Not Contain an “Established Patient” Requirement

While RPM services require an established patient relationship prior to billing RPM codes, RTM services have no such express requirement (at least not yet). We highlighted this distinction in our prior coverage and encouraged stakeholders to submit comments and ask CMS to confirm whether or not the “established patient” requirement applies to both RPM and RTM, or just RPM.

CMS confirmed in the 2024 Final Rule, “RPM, not RTM, services require an established patient relationship after the end of the PHE.” Despite the lack of an express requirement, CMS expressed its belief that RTM services would be furnished to a patient only after a treatment plan has been established (and presumably after the billing practitioner conducted an initial interaction evaluation with the patient).

Under current RTM rules, the failure to conduct an initial patient evaluation and create an “established patient” relationship may not be a per se deviation of RTM billing requirements, but it remains possible that failing to complete this initial interaction and create a treatment plan could expose RTM practitioners to post-payment audits based on Medicare’s “reasonable and necessary” standard. CMS said it will clarify this policy in future rulemaking.

Practitioners Must Collect at Least 16 Days of Data Per 30-Day Period

In the 2024 Final Rule, CMS clarified which remote monitoring codes require at least 16 days of data collection in a 30-day period, and which codes have no such requirement. Prior CMS commentary indicated the RPM and RTM set-up and device codes (CPT codes 99453, 98976, 99454, 98977, and 98978) required at least 16 days of data collection. However, there was ambiguity as to whether or not the 16-day requirement applied to the four treatment management codes (CPT codes 99457, 99458, 98980, and 98981). We highlighted this ambiguity in our previous blog post and encouraged interested stakeholders to submit comments advocating for greater flexibility on the 16-day requirement.

In the 2024 Final Rule, CMS wrote:

We note that in the CY 2024 PFS proposed rule, we inadvertently listed all of the RTM codes (88 FR 53204) in our discussion of these services and had made a general statement about the applicability of the 16-day data collection requirement. 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.

This represents the first time CMS expressly stated in published guidance how the 16-day data collection requirement does not apply to the RPM and RTM treatment management codes (CPT codes 99457, 99458, 98980, and 98981).

Only One Practitioner Can Bill Medicare for RPM/RTM Services

In a given 30-day period, only one practitioner can bill RPM (CPT codes 99453 and 99454) or RTM (CPT codes 98976, 98977, 98980, and 98981), and only when at least 16 days of data has been collected on at least one medical device. “Even when multiple medical devices are provided to a patient,” CMS explained, “the services associated with all the medical devices can be billed by only one practitioner, only once per patient, per 30-day period and only when at least 16 days of data have been collected.” Moreover, remotely-monitored monthly services should be billed only when reasonable and necessary, consistent with prior CMS guidance.

When reiterating that only one practitioner can bill these codes, CMS did not expressly list the two codes for RPM treatment management services (CPT codes 99457 and 99458), although CMS did list the two codes for RTM treatment management services. In future rulemaking, interested stakeholders should consider asking CMS to clarify whether or not multiple practitioners can bill CPT codes 99457 and 99458 for the same patient in the same 30-day period. Until then, while it arguably may not be a per se deviation of RPM billing requirements to have multiple practitioners simultaneously bill Medicare for the same patient, it remains possible that such billing could expose RPM practitioners to claim denials or post-payment audits based on Medicare’s “reasonable and necessary” standard.

Use of RPM/RTM with Other Services

Practitioners are permitted to bill Medicare for RPM or RTM (but not both) concurrently with the following care management services for the same patient so long as the time and effort is not counted twice: Chronic Care Management (CCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Chronic Pain Management (CPM). By allowing this concurrent billing, CMS intends to afford practitioners maximum flexibility when selecting the right combination of care management services for patients, while still guarding against fraud, waste, and abuse.

This restriction is not limited to Medicare. The 2023 CPT Codebook Guidance explains that CPT code 98980/98981 (RTM treatment management) cannot be reported in conjunction with CPT codes 99457/99458 (RPM treatment management).

Billing RPM or RTM During Global Surgery Periods

When a billing practitioner furnishes a procedure or surgery subject to a global billing period (where the practitioner receives a lump payment covering the post-surgical follow-up services within the global period), that practitioner cannot bill Medicare for RPM or RTM services provided to the patient during that global period. This is because the global billing payment received by the practitioner covers those post-surgical follow-up services during the period. This policy was clarified in the 2024 Final Rule.

However, the policy that prohibits RPM or RTM services being furnished during the global period only applies to billing practitioners who are receiving the global service payment. Practitioners, such as therapists, who are not receiving a global service payment because they did not furnish the global procedure, are permitted to furnish RPM or RTM services during a global period. Providing RTM or RPM services during the global period is permitted if the practitioner is not receiving global service payment because they did not furnish the global procedure. This means, for example, a doctor can perform surgery on a patient under global billing, and a physical therapist can enroll the patient in the therapist’s RTM program for post-surgery rehab and monitoring.

Correspondingly, CMS explained how, for a patient who already is receiving RPM or RTM services during a global period, a practitioner may furnish RPM or RTM services (but not both) to the patient, and Medicare will pay the practitioner separately for the RPM or RTM, so long as the remote monitoring services are unrelated to the diagnosis for which theglobal procedure is performed, and as long as the purpose of the remote monitoringaddresses an episode of care that is separate and distinct from the episode of care for theglobal procedure – meaning that the remote monitoring services address an underlyingcondition that is not linked to the global procedure or service.

FQHCs and RHCs May Receive Separate Reimbursement for RPM and RTM Services

Historically, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) were not authorized to separately bill for RPM and RTM services, and payment was made through an all-inclusive rate rather than separate reimbursement. Beginning January 1, 2024, FQHCs and RHCs may now separately bill Medicare for RPM and RTM. They do so using the general care management code (HCPCS code G0511) on an FQHC or RHC claim form. The RPM/RTM services must be medically reasonable and necessary, meet all the coding requirements, and cannot be duplicative of services already paid for under the general care management code for an episode of care in a given calendar month.

RHCs and FQHCs may bill HCPCS code G0511 multiple times in a calendar month, according to CMS’ commentary, provided all requirements are met and resource costs are not counted more than once. CMS will post the final 2024 payment rate for the general care management HCPCS code G0511 on the RHC and FQHC center websites (which can be accessed here and here).

Physical Therapists and Occupational Therapists can Bill RTM for Assistants Under General Supervision

Physical therapists (PTs) and occupational therapists (OTs) can provide and bill Medicare for RTM services. However, Medicare regulations for PTs and OTs in private practice (PTPPs and OTPPs) required all physical and occupational therapy services in that setting to be performed by, or under the direct supervisionof, the PT or OT. Requiring direct supervision levels renders it difficult for PTPPs and OTPPs to bill for RTM services performed by assistants (PTAs and OTAs) under their supervision.

Beginning January 1, 2024, Medicare will only require general supervision for PTPPs and OTPPs to bill for RTM services furnished by their PTAs and OTAs. This change is accomplished through the establishment of an RTM specific general supervision provision in 42 C.F.R. § 410.59(a)(3)(ii) and (c)(2) and 42 C.F.R. § 410.60(a)(3)(ii) and (c)(2). One caveat to this change: Medicare will continue to require PTPPs and OTPPs to directly supervise their employed PTs and OTs if the PT or OT being supervised is not individually enrolled in Medicare.

RPM is Not Included in the Definition of Primary Care Services for MSSP

In the Proposed Rule, CMS considered adding RPM CPT codes 99457 and 99458 to the definition of primary care services used for purposes of beneficiary assignment in the Medicare Shared Savings Program (MSSP). In the Final Rule, however, CMS chose not to add those codes.

Based on its commentary, CMS’ concern is that while RPM codes could be billed by primary care providers to support the overall management of a patient’s care, the codes can also be billed by specialists. Because only one treating practitioner can bill RPM for a given patient, if a specialist bills these codes to support management of a specific condition, the patient’s primary care provider would not be able to also bill RPM treatment management services for the patient. As a result, including the RPM codes in the definition of primary care services for purposes of assignment could inappropriately affect the determination of where a beneficiary received a plurality of their primary care services under MSSP rules.

Conclusion

The 2024 Final Rule reflects a continued maturation of RPM and RTM Medicare billing guidance. However, there continues to be some lack of clarity in the operation of RPM and RTM codes, some of which has been created by the iterative rulemaking process itself. Stakeholders should consider participating in future rulemaking in greater numbers to more quickly resolve some of the areas of uncertainty to allow these services to be better used to support increased quality and innovation in digital health models available to patients. 

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First, the bad news: The final 2024 Physician Fee Schedule rule rolled out by the U.S. Centers for Medicare & Medicaid Services contains virtually the same cuts to payment under Medicare Part B as were in the proposed rule. But this time around, there’s also good news: Many of the more positive elements in the proposed rule also remain, as does the possibility for future favorable shifts, particularly around PTA supervision. While final rule’s 3.4% reduction to the conversion factor shows the agency continuing down an unsustainable path that will require both short- and long-term congressional intervention, several of the provisions set to be put in place Jan. 1 are clear advocacy wins for APTA and its supporters.

Here’s an overview of the major elements of the final rule. (For additional insights, join us on Nov. 16 for a live webinar on the final rule. It’s free for APTA members and available at a significantly reduced rate for non-members.)

The conversion factor cuts are harmful, but they could’ve been worse, and KX modifier thresholds were adjusted.
The final rule includes another decrease in the conversion factor, one of the elements used in calculating final payment amounts for various codes. This time around, the conversion factor as initially reported by CMS is $32.7375, a 3.4% decrease from the $33.8872 conversion factor adopted in 2023. The impact of the cut is far-reaching, affecting more than 27 specialties including physical therapy.

While still damaging, the cut was less than the anticipated 4.2% drop. The reason, according to CMS, is that it reconsidered utilization estimates of a particular evaluation and management add-on code, which in turn allowed the agency to lessen the cuts to the conversion factor. CMS must make the reductions to the conversion factor to offset the evaluation and management increases in order to maintain budget neutrality.

Now that the final rule has been issued, the only possibility for relief from the cuts comes by way of Congress, which could step in with last-minute appropriations, as it did for the past three years.

APTA will be advocating for a similar short-term fix this year. At the same time, the association will continue its press for long-term solutions, pointing to the cuts as symptomatic of an outdated payment system. APTA, APTA Private Practice, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have presented Congress with a set of policy principles as a first step toward an overhaul.

Also in the final rule: CMS set the threshold for use of the KX modifier — the modifier indicating that a service meets the criteria for a payment ceiling exception — at $2,330 for PT and speech-language pathologist services combined, and $2,330 for occupational therapy services. The Medical review threshold remains at $3,000 through 2027.

The practice expense elements for 19 therapy codes could potentially increase.
In early 2023, APTA made the case to CMS that several codes frequently used by PTs are subject to a kind of double jeopardy that unfairly cut values. The association offered two arguments: First, that   codes including therapeutic exercises, neuromuscular reeducation, gait training, and therapeutic activities were undervalued by the AMA Relative Value Scale Update Committee, or AMA RUC, that sets payment rates typically adopted by CMS; and second, that these codes simultaneously were subject to reductions associated with the Multiple Procedure Payment Reduction system. APTA asserted that both devaluations are being made for the same ostensible reason — to account for a duplicative practice expense when multiple codes are used on the same day. APTA told CMS that discounting codes twice for the same rationale didn’t make sense.

CMS listened, and in the final rule directs the AMA RUC to re-review its earlier value recommendations — a provision unchanged from the proposed rule. The list of affected codes can be found on Page 96 of the final rule. The codes up for reconsideration have already been added to the AMA RUC’s January meeting agenda; APTA believes that the values of many of the codes will be increased.

New caregiver training codes are on the books.
In another win for APTA, CMS finalized the adoption of codes that would allow PTs, OTs, SLPs, and other providers to bill for providing training to caregivers when a patient with a functional deficit is not present. APTA created the codes, submitted them for AMA consideration, and argued for their valuation levels at the AMA RUC level.

The final rule includes a definition of caregiver that’s broader than CMS’ earlier definition, which had limited the term to relatives of the beneficiary. The new definition, strongly supported by APTA, expands “caregiver” to include “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation,” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

The codes, found on Page 285 of the final rule, will be considered “sometimes therapy” and thus not subject to the Multiple Procedure Payment Reduction system. Despite APTA’s advocacy otherwise, the codes won’t be eligible for use in association with telehealth.

CMS provided clarifications on telehealth coding and reporting remote therapeutic monitoring treatment management codes.
CMS followed through from the proposed rule and corrected its mistake that excluded PTs in institutional settings from participating in the telehealth extension that is in place through 2024. Under the final rule, these PTs can participate in telehealth in the same way as PTs in private practice settings — by using the same 95 modifier that they’ve been using since the beginning of the public health emergency. The CMS decision settles, for now, the issue of whether PTs would be required to use new Place of Service codes that CMS adopted. They aren’t.

Also in the final rule, CMS responded to a criticism from APTA that requiring 16 days of monitoring for codes 98980 and 98981 — treatment management codes that account for time spent in a calendar month — isn’t appropriate for these types of services. CMS agreed, and clarified that the 16-day collection requirement doesn’t apply to the two codes.

The rule features more positive movement on PTA supervision, including deeper consideration of general supervision in private practice settings, an extension of virtual supervision allowances, and relaxation of supervision associated with RTM.
The proposed rule included a request for comments on the possibility of moving away from direct supervision of PTAs and occupational therapy assistants in private practice — currently the only setting under Medicare in which 100% on-site supervision is required — in favor of general supervision. APTA made this topic a central feature of its comments to CMS on the proposed rule and urged members to do the same in their individual letters to the agency.

While the final rule doesn’t change the current requirement, it does include a lengthy discussion of the evidence APTA and other commenters provided, including reference to a report commissioned by a coalition of provider groups including APTA that found that a change to general supervision of PTAs in private practice settings could result Medicare savings of $271 million over 10 years. CMS offered its standard language on comment solicitations in the final rule, stating that “we will take these comments into consideration for possible future rulemaking” — but the sheer length of the discussion in the rule may be a good sign.

The final rule also follows through on a proposal to extend virtual supervision of PTAs and OTAs through the end of 2024, and finalizes a general supervision-only requirement for PTAs performing remote therapeutic monitoring regardless of setting.

PTs get their first-ever opportunity to participate in the MIPS Value Pathways Program by way of the first cost measure they’ll be able to report — and will begin MIPS reporting on interoperability.
The rule finalizes several proposed changes to the PT’s role in the CMS Quality Payment Program, or QPP, specifically within the Merit-based Incentive Payment System, or MIPS, and its MIPS Value Pathways program, or MVP.

First, the rule incorporates a new, APTA-recommended MVP based on musculoskeletal care, with a single — and also first-ever — cost measure PTs can use on low back pain. The rule also calls for APTA and other entities to submit existing measure recommendations through the MVP maintenance process, and to work with measure developers to create additional measures for inclusion in the MIPS measure inventory.

Second, CMS will no longer exempt physical therapy practices of 16 or more clinicians from the promoting interoperability category of MIPS, which will in turn require practices to have certified electronic health records technology in place for at least six months in 2024 (practices of 15 or fewer clinicians will still qualify for the exemption). Bottom line: All clinicians (except for clinical social workers), including PTs, will have their MIPS scoring weighted normally in the interoperability category in the 2024 performance year. The change wouldn’t apply to hospital-based clinicians and clinicians in small practices. APTA will issue extensive guidance on how to comply with the new QPP policies in the coming weeks.

Want to take a deeper dive into the 2024 fee schedule?  Join us on Nov. 16, 2023, for a special edition live webinar led by APTA staff: CMS 2024 Physician Fee Schedule Final Rule. The event, which offers CE credits, is free to APTA members and available to non-members at a significantly reduced rate. Register today and spread the word.

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Time’s up and pencils down! Comments on the calendar year (CY) 2024 physician fee schedule (PFS) proposed reg were due earlier this week. Now, the Centers for Medicare & Medicaid Services (CMS) will have to review them and issue a final reg on or before November 1, 2023—60 days before the start of the new year.

There are thousands of comments on this massive reg, and it will take a while to go through them all. However, my colleague Kristen O’Brien and I want to highlight some of the initial themes we have identified.

First, a note: physicians and other provider groups are not the only ones submitting comments.

And why is that? It’s because the policies and payment rates established in the PFS reg not only impact Medicare, but also can affect corresponding private insurance and Medicaid policies. As a result, a broad range of stakeholders, including hospital groups, technology companies and private insurers, typically weigh in as well. Even within certain stakeholder groups, there may not be consensus on certain issues. So, let’s dig in on some of the main themes in the PFS comments.

The Most Divisive Issue

Although provider groups expressed universal concern and disappointment about the proposed 3.3% cut to the PFS conversion factor (especially given the expected 4.5% increase in inflation next year), the groups were split on their opinions about the main contributor to the cut: the proposed add-on code for complexity, G2211. (As a reminder, CMS proposed this code as a way to capture the additional time and resources needed to care for a patient with a complex medical condition.) In general, family and internal medicine organizations supported the code, while others, mainly specialists like surgical groups and emergency medicine organizations who would not use the code as proposed, mainly opposed it. However, both stakeholders who supported the code and those who opposed it did agree that CMS overestimated how often the code would be used. While CMS significantly reduced its initial utilization assumptions (from 90% to 38%), they are still significantly higher than the actual utilization of other similar codes, such as chronic care management (found on 2.3% of total claims) and transitional care management services (found on 9.3% of eligible claims). Many were skeptical of CMS’s projections and asked for refinements in the final reg.

It is important to remember that CMS’s assumptions about utilization are just that: assumptions. They may be wrong. But whether they are correct or not, the impact of the assumptions on the PFS conversion factor is real and is creating concern across stakeholder groups. Given that it often takes time to change billing and coding practices, many believe that CMS should recognize there will likely be a delay in the uptake of the new codes, and that more conservative estimates might be more appropriate.

Asking for More Clarity

Telehealth 

CMS also received a lot of comments around the use of telehealth. Most provider groups and telehealth stakeholders supported the continued flexibility that CMS is proposing to provide, including 1) keeping the telehealth codes that were added to the Medicare Telehealth List during the COVID-19 public health emergency on the list through CY 2024; 2) extending the direct supervision waivers and 3) allowing providers to bill at the higher, non-facility rate for telehealth services provided while patients are located in their homes. The consensus was that telehealth continues to benefit patients, improve access, and should be supported beyond the pandemic.

Despite this support, many stakeholders wanted more clarity from CMS on the future direction of telehealth. Specifically, what will billing, coding and payment look like in the future, and why are we continuing to offer only incremental or temporary steps in some instances? While the agency proposed to refine its process for covering and paying for telehealth services, many wanted a clearer picture of how this would work in practice—and whether it still sets the bar too high based on the available evidence related to telehealth. The American Medical Association (AMA) Relative Value Scale Update Committee (RUC) has started evaluating 17 new telehealth evaluation and management (E/M) codes that could be implemented in the PFS in the future. And yet, the initial interim RUC recommendations for these new codes were not addressed in the proposed reg. Many commenters believed that it would be prudent for CMS to wait to alter its Medicare telehealth payment policies until the agency has a chance to evaluate the new codes and signal a clearer direction for telehealth in the future.

Remote Monitoring Services

Numerous stakeholders weighed in on CMS’s proposed clarifications to remote monitoring services, including both remote physiological monitoring and remote therapeutic monitoring services. CMS had also requested additional information from healthcare providers and other stakeholders regarding the use of remote monitoring, remote cognitive behavioral therapy (CBT) and other digital therapeutic modalities. Groups were overall concerned that the clarifications CMS provided would create restrictions or limitations that could temper the use of the clinically appropriate and medically necessary services. Further, groups in support of digital CBT services touted the effectiveness of these treatments and requested that CMS move forward immediately with establishing coverage pathways for them in the final reg.

United Voices

Where commenters seem to agree is in their concern over the direction CMS is heading with the Quality Payment Program (QPP), including the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Many physician groups opposed the proposed increase in the MIPS performance threshold from 75 points in 2023 to 82 points in 2024, noting that this increase is too sharp given that many clinicians have not had to report the last few years because of the COVID-19 hardship exemption. Further, they pointed to CMS’s own estimate that if the policy were finalized, more than half of all clinicians (including 60% of small groups) would fail to meet the threshold and would therefore receive a penalty. Groups also requested that CMS explore ways to make MIPS more meaningful to providers, including making changes to the MIPS Value Pathways (MVP) approach that CMS is moving toward. For example, the AMA believes that MVPs mirror traditional MIPS too closely, and that CMS should “meaningfully reduce burden for participants by increasing scoring simplicity and predictability, removing the population health measures unless relevant to the MVP, aligning performance goals across the four MIPS categories, and increasing flexibility for CEHRT [certified electronic health record technology] use and demonstration.”

With respect to Advanced APMs, groups were concerned about the lack of opportunities for specialists to meaningfully participate in innovative models. Further, they opposed CMS’s proposed change in determining who is a qualifying APM participant (QP). (In order to be exempt from MIPS and qualify for an Advanced APM bonus, clinicians must provide at least a certain percentage of their payments or care for a certain percentage of their patients through the Advanced APM. Clinicians who meet this threshold are called “QPs”.) Since the inception of the QPP, QP status has been determined at the Advanced APM entity level rather than at the individual clinician level. This year, CMS proposes that—beginning with the QP performance period for CY 2024—it would make all QP determinations at the individual level. Most groups believe that this change would make it even more difficult for specialists to meet the QP thresholds.

Finally, there was near-universal support for these proposals:

• To continue to delay the transition to using only time to determine the substantive portion of a split (or shared) service through the end of CY 2024
• To continue not imposing financial penalties on providers who fail to comply with the requirement regarding electronic prescribing of controlled substances
• To indefinitely delay implementing the Appropriate Use Criteria Program
• To establish new codes and payments for community health integration services, social determinants of health risk assessment, and principal illness navigation services provided by social workers, community health workers and other auxiliary personnel (although some commenters urged CMS to go even further and expand the scope of these services)
• To make certain changes to the Medicare Shared Savings Program and the national accountable care organization (ACO) program, including capping the regional risk scores and using the same risk model in the benchmark and performance years (there was, however, nearly universal opposition to requiring all ACOs to report the Promoting Interoperability category of MIPS, regardless of track or QP status)

As noted, we are still pouring over different stakeholder reactions and expect that more nuanced trends and themes could emerge. We also know that the possibility for congressional action could further shape both the outcome of CMS’s rulemaking and the ultimate impact on physician and clinician practices. We would love to hear any thoughts from you on reactions to the reg and key issues you’re seeing and tracking.

Until next week, this is Jeffrey (and Kristen) saying, enjoy reading regs with your eggs.

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