RPM Manual
The practical 2026 guide to device rules, day thresholds, management time, and audit defensibility for Remote Patient Monitoring.
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Compliance Advisory
The Compliance Risks of “Block Gapping” in RPM
The hidden risk of “pausing” patient care to avoid failed 99454 months.
Date: December 12, 2025
For: Practice owners, billing leaders, compliance teams
Scope: Medicare RPM device supply (99454)
How to use this page: Operational compliance guide, not legal advice. Confirm payer-specific rules and maintain documentation for medical necessity, consent, device qualification, and billed dates of service.
Quick Snapshot
Risk pattern
“Pause the clock” between cycles
Core concern
Period manipulation + inducement exposure
Better path
Consistent periods
Documented interventions
Explicit episode end/restart
Overview
Medicare RPM device supply billing (CPT 99454) is tied to a hard threshold: CMS describes RPM device supply as requiring a medical device that digitally collects/transmits data on 16 or more days in a 30-day period.[1]
When patients stop taking readings, some teams try to avoid an unbillable month by “pausing” between cycles until adherence returns--often called block gapping. The risk is that pausing can become a billing strategy that distorts the service period, undermines the continuity Medicare expects, and may create beneficiary-inducement exposure if the device remains in the home while billing is on hold.
Section Index
- Key takeaway in one sentence
- What “block gapping” is
- Why auditors view it as high-risk
- The “free device” problem and beneficiary inducement exposure
- Medical necessity and the “on-again/off-again” record
- What to do instead
- FAQ
- References
1) Key Takeaway in One Sentence
If you “pause” 99454 cycles during non-adhesion and restart only when a patient becomes adherent again--while the device remains in the home--you create a pattern that can look like selective billing of profitable windows, increasing denial and audit risk and raising beneficiary-inducement concerns.[1]
2) What “Block Gapping” Is
In a straightforward model, RPM device-supply periods run as consecutive 30-day units once the service episode is established; you either meet the threshold inside each period or you do not. CMS frames eligibility around 16 days in a 30-day period.[1]
Block gapping is the intentional insertion of an unbilled administrative gap between two billed cycles to avoid a likely failed month:
- Cycle 1 bills because the threshold is met.
- The patient stops transmitting.
- Instead of starting the next 30-day period on schedule, the program “stops the clock.”
- The device stays with the patient.
- When readings resume, that day is declared the new start for the next billed 30-day unit.
“Rolling 30 days” is not a license to skip low-adherence time while keeping the episode alive.
3) Why Auditors View It as High-Risk
Selective periods look like manipulation
CMS’ requirement is 16+ days in a 30-day period.[1] Engineering workflows to open only when adherence resumes shapes billing periods to harvest payable segments rather than reflect continuous monitoring.
Cherry-picking is a known RPM fraud pattern
HHS OIG warns that RPM can be abused by billing monthly monitoring that does not occur.[2] Block gapping is different but can appear designed to generate payment without a coherent monitoring episode.
4) The “Free Device” Problem and Beneficiary Inducement Exposure
Block gapping is riskiest when the patient keeps the RPM device during the unbilled gap.
- CMP beneficiary inducement authorities cover remuneration offered to induce beneficiaries to use particular providers/suppliers.[3]
- Remuneration can include free or below-market items or services of value.
- Leaving a device in the home while “the clock is stopped” can create a fact pattern compliance teams must justify.
This is distinct from Anti-Kickback Statute framing; beneficiary inducement exposure lives in CMP authorities.[3]
5) Medical Necessity and the “On-Again/Off-Again” Record
Medicare coverage requires services to be reasonable and necessary.[4] RPM is generally continuous monitoring for ongoing risk. If records show a pause for billing convenience while the device stays deployed, auditors can question why monitoring was clinically necessary only during favorable windows.
Not billing every month is acceptable; shaping the episode to only bill “good months” is not.
6) What to Do Instead
- Keep a consistent service-period definition and track the threshold inside that period.[1]
- When adherence drops, intervene clinically (outreach, troubleshooting, coaching) and document the actions.
- If you suspend or end the episode, do it explicitly: retrieve the device or formally close the episode, and restart with a true new episode and consent as applicable.
- Treat “device stays, billing paused” as a compliance hotspot requiring clear justification.
Time-based management codes may still apply when requirements are met, but they do not justify leaving devices deployed indefinitely without a coherent episode.
How This Relates Back to FairPath
FairPath is designed to prevent silent drift into risky patterns by making states explicit for every patient:
- Active episode: with clear period boundaries and day tracking.
- At risk: pacing alerts surface early warning on threshold risk.
- Suspended/ended: explicit reasons with operational follow-through, including device retrieval policy.
Clarity over manipulation keeps block gapping from becoming an informal “feature.”
FAQ
1
Can we pause the cycle if the patient requests it (vacation, hospitalization, personal reasons)?
Patient-requested, clinically documented suspensions are different from systematically pausing low-adherence patients as a billing optimization. The “reasonable and necessary” standard still governs.[4]
2
Does “rolling 30 days” mean I can start the 30 days whenever I want?
Rolling means not tied to calendar months; it does not authorize omitting inconvenient time while keeping the episode active. The requirement is 16+ days in a 30-day period.[1]
3
What if we retrieve the device during the gap?
Device retrieval with documented episode termination is safer than leaving the device deployed while billing is paused and then restarting when adherence improves.
4
Is it really an inducement if the device is just sitting unused?
“Unused” does not erase value; CMP beneficiary inducement authorities consider remuneration to beneficiaries.[3] Leaving devices in the home during unbilled pauses can raise questions in audit.
5
How does OIG’s RPM warning relate to this?
OIG warns about RPM billing when monitoring does not occur.[2] Gapping can create a similar impression if billing reflects only cherry-picked windows of adherence.
6
Does the 2026 rule change make gapping unnecessary?
Industry summaries reference shorter-duration device-supply options for 2026, but verify specifics in the final rule and MAC/payer guidance before relying on them.[5]
References
- CMS proposed CY 2021 PFS rule language noting 99453/99454 require “16 or more days of data every 30 days.” federalregister.gov.
- HHS-OIG Consumer Alert: Remote Patient Monitoring (fraud risk warning). Office of Inspector General.
- OIG CMP authorities page mapping §1128A(a)(5) to beneficiary inducement. Office of Inspector General.
- Social Security Act §1862(a)(1)(A) (“reasonable and necessary” standard). Social Security.
- CMS CY 2026 PFS fact sheet (verify shorter-duration device-supply options). Centers for Medicare & Medicaid Services.
- CY 2021 PFS telehealth/RPM fact sheet summarizing 16 days of data in 30 days. team-iha.org.
- OIG Work Plan summary noting RPM fraud/abuse susceptibility. Office of Inspector General.
