Remote monitoring still largely non-reimbursable in mental health
The good: In 2023 - for the first time ever - mental health professionals will be able to bill an established CPT code (989X6) for a remote patient monitoring activity [1]. This code is a practice expense code that will reimburse for the cost of devices that monitor the progress and effectiveness of cognitive behavioral therapy (CBT). The questionable: Despite other health care fields being given broadly applicable remote monitoring codes that reimburse for both the device itself and for provider time reviewing data, this code can only be billed for device costs and is only relevant when CBT is being utilized. It remains to be seen exactly how this code will be used within these bounds, but it appears intended to incentivize the adoption of digital therapeutics that provide CBT, as it provides a new mechanism to pay for these products.
The new code comes on the heels of other major coding changes in 2022, which is the first year that health care providers can bill for the review of non-physiologic remote monitoring data with codes 98975-98981, deemed “Remote Therapeutic Monitoring” (RTM) codes, for the review of data including symptom and activity tracking [2]. Prior to this year, providers were only able to bill for the review of physiologic data like blood pressure, heart rate, blood sugar, etc. with “Remote Physiologic Monitoring” (RPM) codes. After much debate over which providers would be able to use 2022 RTM codes, the final ruling stated that the codes could only be used for respiratory and musculoskeletal disorders. These codes will, for example, cover the usage of a hypothetical device that tracks movement and activity in a patient with a movement disorder under the care of a neurologist, but neither now nor in 2023 will there be codes that cover tracking mood and sleep in a patient with depression under the care of a psychiatrist.
We really, really need these activities covered in mental health, which relies almost completely on patient-self reports and clinician observations to diagnose, treat, and monitor conditions, using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a guide. These “snapshots” are only gathered during appointments and provide a narrow view of the patient’s overall mental state [3] [4]. Studies have shown that prevalent diagnoses like major depressive disorder and generalized anxiety disorder have low inter-rater and test-retest reliability [5] [6], which is unsurprising given the lack of data and lack of objective markers of disease. Although there is evidence that more reliance on measurement-based care via symptom rating scales and similar interventions can improve outcomes, only 18% and 11% of psychiatrists and therapists, respectively, routinely use these methods to monitor their patients [7] [8] [9], primarily because they are not reimbursable as isolated activities (considered “bundled” activities), are difficult to implement logistically, and do not provide detailed enough information [10]. Even when utilized, these methods must minimize detail to maximize patient response rate - digital monitoring tools have the power to combat this issue by passively tracking patients and facilitating the process of the patient interacting with the monitoring tool.
Remote monitoring has the power to transform mental health even if we only consider its ability to digitize activities that we already know work (i.e. measurement-based care). Maybe we’ll see more broadly applicable codes in 2024, but it feels like the message being sent to mental health providers is: We’ll reimburse for the remote monitoring activities that help promote digital therapeutics and promote the post-market research of these tools, but otherwise we don’t value remote monitoring activities even if there is evidence that they lead to better patient care. In health care, what isn’t paid for probably won’t happen, and the billing codes available essentially do not pay for remote monitoring in mental health. Hopefully, we’ll see changes soon.
References:
[1] CPT Editorial Summary of Panel Actions September-October 2021. American Medical Association. 2021. https://www.ama-assn.org/system/files/september-october-2021-summary-of-panel-actions.pdf. Accessed 09/13/2022
[2] Ferrante TB. 2022 Medicare Remote Therapeutic Monitoring FAQs: CMS Final Rule. The National Law Review. 2022. https://www.natlawreview.com/article/2022-medicare-remote-therapeutic-monitoring-faqs-cms-final-rule. Accessed: 04/20/2022.
[3] Hirschtritt ME, Insel TR. Digital Technologies in Psychiatry: Present and Future. The Journal of Lifelong Learning in Psychiatry. 2018.
[4] Chauvin JJ, Insel TR. Building the Thermometer for Mental Health. Cerebrum. 2018.
[5] Freedman R, Lewis DA, Michels R, et al. The initial field trials of DSM‐5: new blooms and old thorns. Am J Psychiatry. 2013;170(1):1‐5.
[6] Regier DA. DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses. The American Journal of Psychiatry. 2013.
[7] Zimmerman M, McGlinchey JB. Why don’t psychiatrists use scales to measure outcome when treating depressed patients? Journal of Clinical Psychiatry. 2008;69:1916–1919.
[8] Hatfield D, McCullough L, Frantz SH, Krieger K. Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice. 2010;17(1):25–32.
[9] Fortney J, Sladek R, Unützer J. The Kennedy Forum. Washington D.C: 2015. Fixing behavioral healthcare in America.
[10] Hatfield DR, Ogles BM. Why some clinicians use outcome measures and others do not. Administration and policy in mental health and mental health services research. 2007;34(3):283–291.
