Reimbursement
Information

PT code 98977, billed for the ongoing supply of RTM “devices”, provides reimbursement for device(s) that monitor the musculoskeletal (98977) system. The CPT Codebook states that devices supplied under this code and used for RTM 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. Medicaid program and commercial payors may have more specific rules regarding the types of devices that must be used. 

Importantly, the FDA’s definition of a “medical device” includes certain software functions intended to diagnose, cure, mitigate, treat, or prevent disease. More information regarding medical devices under the FD&C Act can be found on the FDA website. 

Yes. Augment Therapy’s software, ARWell PRO, meets the “Software as a Medical Device” criteria as defined by the FDA.

This is ultimately determined at the discretion of the billing practitioner. To comply with the requirements of codes 98975 and 98977, RTM should be used to monitor a musculoskeletal condition. Some common eligible patient conditions potentially include any diagnosis that impacts bone, muscle, tendons and/or   ligaments and results in loss of mobility, function, and/or strength when paired with a musculoskeletal device under 98977.  

There is no explicit pre-authorization requirement for Medicare beneficiaries of RTM services. However, individual state Medicaid programs and commercial plans may require pre-authorization prior to delivery and coverage of RTM services. Providers should therefore look to applicable commercial and state Medicaid policies to determine whether additional pre-authorization is required.   

Yes, for Medicare beneficiaries. 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. Copay requirements may vary under state Medicaid and commercial payor plans but are often required.   

Providers should follow current billing practices and ensure that all the requirements for each code are met, such as documenting medical necessity for ordering RTM services and patient consent in the medical record. 

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. This 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 

• Registered Dietitians or Nutrition Professionals 

Billing practitioner eligibility can vary under State Medicaid and commercial plans. Providers should therefore look to applicable commercial and state Medicaid policies. 

No. The CPT Codebook states that RTM and RPM should not be billed for the same patient in the same month.  

Yes. The CPT Codebook states that CPT codes 98975 and 98977 should not be reported if monitoring is less than 16 days. There is no prohibition, however, on billing the treatment management services codes (CPT codes 98980 and 98981) if less than 16 days of transmissions have occurred as along as the 20 minutes of time has been accrued and all other billing requirements are met.  

CMS does not specifically define “physiologic” data for RPM or “non-physiological” data for RTM. 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 response. Providers should use their professional judgment in determining what constitutes “non-physiologic” or “therapeutic” for purposes of RTM. 

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

YYou can confirm current Medicare reimbursement amounts by searching for the relevant RTM CPT code, including a breakdown of payment amounts by geography, at https://www.cms.gov/medicare/physician-fee-schedule/search/overview. Commercial payor reimbursement varies by payor, plan, and geography. Confirm with each contracted payor’s fee schedule.