Billing RPM Under Capitation Agreements

How to think about Remote Patient Monitoring when you’re paid under Medicare Advantage and other capitated models.

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Remote Patient Monitoring (RPM) codes 99453, 99454, 99457, and 99458 are designed to be paid separately under Medicare’s fee-for-service schedule. Under capitated arrangements or managed-care contracts (including many Medicare Advantage plans), however, those same services are often treated as part of the global payment you already receive.

This page explains how fee-for-service Medicare and capitated models treat RPM differently, why you see CO-24 denials (“charges covered under a capitation agreement or managed care plan”), and what practical options you have when RPM isn’t separately reimbursable.

Understanding Coverage Models

Traditional Medicare vs. Medicare Advantage

Traditional Medicare (Fee-for-Service)

  • RPM services are separately billable and reimbursable under Original Medicare (Part B), subject to all standard RPM rules (medical necessity, device days, management minutes, coinsurance).
  • CMS created 99453/99454/99457/99458 specifically to pay for device set-up, supply, and remote treatment management time as care-management services.
  • Claims for eligible patients go directly to Medicare and are paid under the Physician Fee Schedule, one line item per service.
  • There is no capitation in standard Part B – RPM appears as its own reimbursable service if all requirements are met.

Medicare Advantage (Part C) & Managed Care

  • Medicare Advantage plans must cover all Part A and B benefits (including RPM), but they pay providers according to their own contracts, not the Part B fee schedule.
  • Many plans and risk-bearing entities pay physicians on a capitated basis (PMPM) for all “covered services” for attributed members.
  • In those settings, RPM codes are frequently treated as “included in capitation” rather than separately payable line items.
  • Claims for 99453–99458 often return with denial code CO-24 – “charges are covered under a capitation agreement or managed care plan.”

Carve-Outs, Exceptions, and RHCs/FQHCs

  • Not all managed-care contracts are identical. Some plans carve out specific services from capitation and pay them fee-for-service on top.
  • Historically, RPM codes are rarely carved out by default; most plans group them into routine care covered by the PMPM payment unless the contract says otherwise.
  • CMS has not mandated separate RPM payment for MA enrollees; it leaves payment mechanics to the plan and your contract.
  • As of 2024, CMS created a carve-out for RHCs/FQHCs, allowing RPM/RTM to be billed via G0511 as general care management. That exception proves capitation systems can carve RPM out – but unless your contract says so, assume RPM is bundled.

Optimizing Your Approach

Best Practices for RPM in Capitated Plans

When patients are in Medicare Advantage HMOs or other capitated plans, RPM is often clinically valuable but financially tricky. These practices help you avoid wasted effort and unnecessary denials.

Verify Plan Type and Attribution Up Front

Confirm if the patient is on Original Medicare, Medicare Advantage, or another managed plan before you bill. For MA and risk contracts, identify whether you are the capitated primary entity responsible for that member. If you send RPM claims to Medicare for an MA member, expect CO-24 telling you to bill the plan or risk-bearing entity instead.

Read Your Contract for Carve-Outs

Examine your managed-care agreement or provider manual to see whether RPM codes (99453–99458 and successor codes) are carved out or listed under “additional care-management” payments. If the contract is silent, the safest assumption is that RPM is bundled into capitation unless you obtain written clarification to the contrary.

Avoid Non-Payable Claim Volume

If you know a plan treats RPM as part of capitation and will reliably deny 99453–99458 as CO-24, it may be more efficient to not submit RPM claims at all for those members. Continue to document RPM work internally for quality and risk purposes without generating a stream of known denials.

Bill Precisely When You Can Bill

When a payer or contract explicitly allows RPM fee-for-service, make sure you meet all standard RPM rules (device days, management minutes, interactive communication). Use the correct place of service: RPM is a care-management service, not a telehealth visit, so it does not use telehealth POS or modifiers unless the plan specifically requires them.

Get Plan Policies in Writing

Ask provider relations or billing support directly: “Are RPM codes 99453, 99454, 99457, 99458 (and their 2026 successors) payable outside of capitation for our contract?” A short email or policy excerpt that answers this is more valuable than a long appeals history.

Addressing Challenges

Handling CO-24 Denials and Appeals

Even with a good strategy, you will occasionally see CO-24 denials on RPM claims. Use them as signals about your contracts and routing, not just as coding errors.

Confirm You Billed the Right Payer

A CO-24 on a Medicare remittance frequently means “this is an MA member” rather than “RPM is not covered.” Confirm the patient’s enrollment and make sure you submitted to the MA plan or risk-bearing entity when appropriate. If you billed the wrong payer, the fix is resubmission, not appeal.

Check Attribution and Contract

Determine whether you are the capitated primary provider for that member. If you are the risk-bearing entity, the CO-24 is usually just your contract speaking: the service is bundled. If you are not capitated for that member (for example, you are a specialist), there may be room to question whether your RPM work is truly included.

Appeal Only When Something Is Wrong

If the contract clearly states that you are prepaid for “all covered services,” an appeal is unlikely to overturn a CO-24 denial. Appeals are more appropriate when there is a mismatch between written policy and system behavior (for example, the provider manual says RPM is separately payable, but the claims engine denies it as capitated).

Use Denials as Contract Intelligence

If repeated CO-24 denials are contractually correct, treat them as a reminder to change your approach: negotiate carve-outs, adjust your billing strategy, or focus on alternative codes and performance incentives. Don’t build your workflow around appeals that are structurally doomed.

Key point: a CO-24 denial usually reflects the payment model, not necessarily a coding error. Use appeals to correct routing and policy mismatches; use contract negotiations and alternative billing for true capitation issues.

Finding Solutions

Alternative Strategies When RPM Isn’t Separately Paid

If RPM codes are bundled in your capitation and not reimbursed fee-for-service, you still have levers to align clinical work with revenue.

Chronic Care Management (CCM)

Many RPM-eligible patients also qualify for Chronic Care Management under Medicare or MA. Codes like 99490 (20 minutes of non–face-to-face clinical staff time for 2+ chronic conditions), 99439, and complex CCM codes (99487/99489) remain separately payable in many contracts.

Medicare explicitly allows CCM and RPM in the same month as long as minutes are not double-counted. In capitated environments, CCM may be recognized and paid where RPM codes are not.

Transitional Care Management (TCM)

If your RPM is focused on patients recently discharged from the hospital or SNF, consider TCM codes 99495 and 99496 for the immediate post-discharge window. TCM requires early contact and a timely follow-up visit but can be more reliably reimbursed than RPM under some contracts.

Medicare does not allow TCM and RPM management codes in the same month for the same patient, so choose the one that best matches the service period and contract reality.

Principal Care Management (PCM)

For RPM programs focused on a single complex condition (e.g., heart failure, high-risk hypertension), Principal Care Management codes (such as 99424, 99425) can sometimes be a better fit. They pay for intensive management of one high-risk condition when the rest of the patient’s panel is relatively stable.

Annual Wellness Visits and Preventive Services

Annual Wellness Visits (G0438/G0439) and other preventive services are separately paid by Medicare and MA and can be a natural touchpoint to set up RPM care plans, risk assessments, and preventive strategies. They don’t replace RPM, but they ensure some of the cognitive work is compensated.

Value-Based Bonuses and PMPM Negotiation

In capitated models, the real financial benefit of RPM may be indirect: better blood pressure control, fewer admissions, and improved quality metrics. Those, in turn, feed shared savings, star ratings, and performance bonuses.

Use your RPM data to justify higher capitation rates, additional per-member-per-month care-management fees, or explicit RPM carve-outs by showing how remote monitoring improves outcomes and lowers total cost.

Key insight: even when RPM codes themselves are bundled, the underlying work (monitoring, coordination, outreach) can support CCM, PCM, TCM, preventive visits, and better performance on value-based metrics. The goal is to align that work with revenue streams your contracts actually recognize.

Authoritative Resources

Official Guidance and Policy Signals

When you’re deciding what to bill and when to negotiate, it helps to understand how CMS and regulators are framing RPM in fee-for-service and MA.

CMS and MAC Positioning

Medicare Administrative Contractors and CMS FAQs consistently state that if a patient is in an MA plan, claims for services – including RPM – must go to that plan, not to fee-for-service Medicare. If a service is covered by the plan’s capitation, Medicare’s system will not pay it separately.

RPM as Care Management, Not Telehealth

CMS classifies 99457/99458 as care-management services, not telehealth visits, and allows them under general supervision. That classification carries into MA: plans treat RPM as part of longitudinal care, which is exactly why many see it as bundled into capitation unless carved out.

Concurrent Billing Rules

CMS guidance confirms that RPM can coexist with CCM, PCM, and other care-management programs in the same month as long as the work and minutes are distinct. That’s critical when you pivot away from RPM billing in capitation but still want to capture care-management revenue where allowed.

Oversight and OIG Interest

OIG reports highlight rapid growth in RPM and emphasize oversight in both fee-for-service and MA. MA plans are required to report RPM in encounter data even if they don’t pay separately; regulators care about utilization and integrity whether or not you see a line item on your remittance.

Summary

Most RPM hurdles under capitation are contract and plan-policy issues, not CPT or CMS issues. Traditional Medicare will pay for properly documented RPM, but capitated models often embed that work in the PMPM. The best strategy is to use RPM to improve patient outcomes while aligning your billing with codes and incentives your contracts actually recognize – and negotiating carve-outs or PMPM adjustments where the value is clear.

Need Help Navigating RPM in Capitated Models?

FairPath can help you design RPM workflows that make clinical sense under fee-for-service – and financial sense under Medicare Advantage and other risk arrangements.

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