Remote Patient Monitoring (RPM): A Practical Guide (2026 Update)

The source of truth for the 2026 code split (99445 vs 99454), the unbundling of RHC/FQHC billing, and the specific data signals the OIG is targeting this year.

Clinical Playbooks ↓ Device Rules ↓ 16 Day Rule ↓ 2026 Billing Codes ↓ Audit Proof Pack ↓

Manually tracking 99453, 99454, 99457, 99458, 99445, and 99470 across spreadsheets is a compliance risk.

Let FairPath automate it with the Compliance Scanner.

RPM Compliance Series

Deep dives on the most common 99454 pitfalls and how to keep billing defensible.

The “Block Stretching” Trap (99454)

Why extending the 30-day window to “reach 16 days” misstates the billed unit and risks denials.

Read the Block Stretching Guide

The “Block Gapping” Risk (99454)

How pausing cycles until adherence returns can appear as period manipulation and beneficiary inducement exposure.

Read the Block Gapping Guide

What RPM Is – and What It Isn’t

Remote Physiologic Monitoring

RPM uses FDA-defined medical devices to collect physiologic data at home (e.g., blood pressure, weight, glucose, pulse oximetry) and automatically transmit it to your team for review and treatment decisions.

For Acute or Chronic Conditions

Medicare allows RPM for acute or chronic conditions when remote monitoring is medically reasonable and necessary – for example uncontrolled hypertension, high-risk heart failure, brittle diabetes, or high-risk COPD.

Not Just “More Telehealth Visits”

RPM is not a video visit and not self-reported symptoms. It’s continuous physiologic data plus documented clinical management time, billed under a specific set of Part B codes.

In Medicare’s rules, RPM is distinct from other programs: it uses physiologic data only (RTM covers self-reported symptoms and therapy), requires automatic electronic transmission of data from a medical device, can support acute or chronic conditions, and may run alongside programs like CCM or APCM as long as the work and minutes are documented separately.

RPM is a non face to face service and is not treated as a telehealth visit. It is not constrained by originating site rules because it is not a substitute for an E and M visit.

Operational gate: RPM requires an established patient relationship. Do not enroll and bill RPM for patients who have no prior visit and no documented plan of care.

How a Compliant RPM Program Works

1. Identify Eligible Patients

Start with established patients whose conditions genuinely benefit from home monitoring: uncontrolled hypertension, high-risk heart failure, complex diabetes, COPD, post-discharge risk, etc. RPM is billed per patient, not per diagnosis, and only one practitioner can bill it per month. Operational gate: RPM requires an established patient relationship and a documented plan of care before enrollment.

2. Consent & Baseline

Explain RPM, including Part B coinsurance, responsibilities, and how long they’ll be monitored. Obtain and document consent (verbal or written) and capture a baseline plan so medical necessity is clear in the chart. Operational gate: Document consent once at enrollment and keep the consent date easily retrievable for audit response.

3. Device Setup & Data Capture

Provide a connected medical device (cellular, Wi-Fi, or equivalent) that automatically uploads data. Track usage so you know which patients meet the “16 days of data in 30 days” requirement for the device codes. Operational gate: Track days of transmitted data continuously. Do not wait until month end to discover you missed the threshold.

4. Ongoing Management & Documentation

Clinical staff and clinicians review incoming data, triage alerts, adjust medications, and communicate with the patient. You log this time so you can bill the 20-minute management blocks and defend those claims in an audit. Operational gate: Management codes require at least one interactive communication with the patient or caregiver during the month. Document the date and substance.

Medical Necessity & Clinical Playbooks

To survive an audit, RPM must be more than a "data dump." You need a condition-specific protocol that dictates exactly when your team intervenes.

Example Clinical Protocols (The "Why" Behind the Bill)

Condition	Device Strategy	Alert Thresholds (Examples)	Clinical Action Protocol
Hypertension	BP Cuff (Daily AM/PM)	Critical SBP > 180 or DBP > 110 Urgent SBP > 150 (2+ days)	Assess med compliance/diet. If >150 for 1 week, escalate to MD for titration.
Heart Failure	Weight Scale (Daily)	Critical Weight ↑ >3 lbs in 24h	Nurse call same day to assess edema/SOB. Consider diuretic dose adjustment per standing order.
Diabetes	Glucometer/CGM	Critical Glucose < 70 or > 300	Immediate outreach. For hypo: advise fast-acting carb. For hyper: check ketones/illness.

Compliance Note: Establishing written protocols ("Playbooks") proves that monitoring is reasonable and necessary--your primary defense against OIG scrutiny.

Who Typically Qualifies for RPM?

There is no hard “21-diagnosis list” in the rules. The real test is whether physiologic monitoring is medically necessary and used to guide care.

Common Chronic Use Cases

Hypertension and other cardiovascular disease (heart failure, ischemic heart disease).
Type 2 diabetes and complex metabolic disease.
COPD and other chronic lung disease at high risk of exacerbation.
Chronic kidney disease where weight and blood pressure trends matter.
Obesity-related conditions where weight trends affect management.

Eligibility & Relationship Rules

Patient is an established patient of the billing practitioner.
RPM addresses an acute or chronic condition with a clear care plan.
Explicit patient consent is documented in the record.
Only one practice bills RPM for that patient per 30-day period.

Consent, Supervision, and Who Does the Work

RPM scales when the work is performed by a care team under supervision with clean documentation. This section covers the operational expectations that auditors test.

Consent

Obtain consent at enrollment and document the consent date in a place your billing team can retrieve quickly.
Explain Part B cost sharing and patient responsibilities (measurement cadence and responsiveness to outreach).

Supervision and incident to

Clinical staff can perform day to day RPM tasks under supervision as part of the physician or QHCP plan of care.
If you use contracted personnel, treat them as auxiliary staff: define scope, protocols, escalation rules, and documentation standards.
Only one practitioner should bill RPM for a given patient in a period. Establish an internal rule for ownership to prevent duplicate billing.

Best practice: document an internal “order” or plan note to enroll the patient in RPM, even if your payer does not require an ordering field on the claim.

Device Requirements That Make or Break RPM Billing

RPM is not “an app plus a spreadsheet.” The device and transmission rules are binary. If you miss them, the claim is not defensible.

FDA defined medical device

The monitoring equipment must be a medical device, not a general wellness gadget. Use devices that clearly fall under medical device regulation for the physiologic measure being captured.

Automatic electronic transmission

Data must be electronically collected and automatically uploaded to a secure system for review. Hand typed logs and patient entered values do not qualify as RPM data.

Retention and export

Assume you will need to produce device reports and timestamps years later. Your RPM platform should support exportable reports and secure retention for audit response.

RTM is the right framework for patient reported symptoms and therapy adherence. RPM requires objective physiologic measures transmitted by an eligible device.

Devices That Count for RPM

Under Medicare, RPM devices must be medical devices that automatically upload data. Hand-typed logs and symptom surveys don’t qualify.

Blood Pressure Monitors

Connected cuffs are the backbone of RPM for hypertension, heart failure, and kidney disease.

Weight Scales

Used for heart failure, CKD, and obesity-related programs where daily weight trends matter.

Glucose & Related Devices

Glucose meters or CGM bridges for diabetes management, when trends are actively managed between visits.

Pulse Oximeters & Others

Oximetry and other physiologic sensors where remote monitoring can realistically change decisions.

Devices can be shipped or supplied in clinic, and some programs support BYOD for patient convenience. However, RPM still requires an eligible medical device and automatic transmission to a secure system. When patients use their own device, operators should be cautious about assuming device supply billing unless the program can produce defensible records that the device and transmission requirements were met and that the supply component was actually furnished.

Who Pays for RPM?

RPM is primarily a Medicare Part B benefit today, with broad but not universal adoption by Medicare Advantage, Medicaid, and commercial plans. You should always confirm specific payer policies, but the high-level pattern is consistent.

Medicare & Medicare Advantage

Medicare Part B covers RPM for acute or chronic conditions when medically necessary, subject to standard 20% coinsurance.
Many Medicare Advantage plans mirror Medicare’s structure and often reduce or waive patient copays, depending on the contract.

Medicaid & Commercial Plans

More than forty state Medicaid programs now reimburse some form of RPM, but covered codes and limits vary by state.
Most large commercial payers key off Medicare’s RPM framework; local coverage decisions and contract language still matter.

The 16 Day Rule: Day Counting That Holds Up in Audit

The most common RPM denials are not “clinical.” They are mechanical. Your device supply billing lives or dies on day counts and clean period boundaries.

What counts as a day

A day counts when at least one measurement is taken and transmitted from the device on that calendar day. Operators should target well above the minimum to create buffer.

What the rule applies to

The day requirement applies to device supply and setup logic. The management time codes are time based and have their own interactive communication requirement.

Mid month rescue

If a patient is trending below threshold, intervene before the month closes: troubleshoot device pairing, replace hardware, reset expectations, or discontinue if adherence is not realistic.

Operator rule of thumb: aim for 20 plus transmitted days so travel, device failure, and patient churn do not turn into write offs.

The 2026 RPM Code Structure

Effective January 1, 2026, the "all or nothing" 16-day rule is gone. You must now select the precise code based on data volume and time spent.

Category	Code	Requirements (2026 Rules)	Approx. Rate*
Setup	99453	Initial Setup & Education. Billed once per episode of care. Requires the device to be used for at least 16 days in the first 30-day period to be payable.	≈ $19 (one-time)
Device Supply (Select ONE per 30 days)	99445 NEW	Low-Volume Data (2–15 Days). Covers device supply and transmission when 2 to 15 days of data are collected. Replaces write-offs.	≈ $47
Device Supply (Select ONE per 30 days)	99454	Standard Data (16–30 Days). Covers device supply and transmission when 16+ days of data are collected.	≈ $47
Management (Select ONE base code)	99470 NEW	Brief Management (10–19 Mins). Requires at least one interactive communication. Use when time does not reach the full 20 minutes.	≈ $26
	99457	Standard Management (20 Mins). Requires 20+ minutes of clinical staff time and at least one interactive communication.	≈ $48
	99458	Add-on (Additional 20 Mins). Billed in addition to 99457 for extra blocks of time. (Cannot be billed with 99470).	≈ $42

Critical Warning for RHCs & FQHCs

Stop using G0511 for RPM. As of January 1, 2026, the bundled G0511 code is obsolete for RPM services. RHCs and FQHCs must now unbundle and report the individual CPT codes (99453, 99454, etc.) to receive payment. Continued use of G0511 will result in denials.

Compliance: The OIG's 2026 "Fraud Signals"

The OIG is no longer just "watching." They are auditing based on specific quantitative patterns. Here are the exact signals we monitor to keep your practice safe.

The "150% Spike" Rule

OIG Signal: Patient enrollment increasing by >150% in a single month is a primary fraud indicator.

The Fix: Avoid mass-enrollment events. Ensure every patient has a prior E/M visit and documented medical necessity before enrollment.

The "43% Failure" Stat

OIG Signal: 43% of RPM patients failed to receive all three required components: Education, Device Supply, and Management.

The Fix: Never bill a monthly cycle unless you can prove Data Transmission AND Interactive Management occurred in the same period.

Vendor "Per-Patient" Fees

OIG Signal: Vendor fees calculated as a % of reimbursement or "per patient" fees for redundant services (Advisory Opinion 25-08).

The Fix: Ensure your vendor charges a Fair Market Value (FMV) flat fee for technology, unrelated to your billing volume.

Device Days Mismatch

Audit pattern: Device supply billed in months where the data days do not support the unit.

Operator fix: Gate device supply billing on a provable report of transmitted days per period and keep the report exportable.

No Interactive Communication

Audit pattern: Management time billed with no documentation of a two way interaction with the patient or caregiver.

Operator fix: Require at least one documented interaction per month when billing management codes, including date and brief substance.

No Established Patient Relationship

Audit pattern: RPM billed for patients with no prior visit history or no documented plan of care.

Operator fix: Make the initiating visit and medical necessity statement a required enrollment artifact.

Monthly Billing "Readiness Gates"

Before submitting any RPM claim, run this 4-point check to prevent automated denials.

Data Volume Check:
Did the patient transmit data on at least 16 days (Bill 99454) or 2–15 days (Bill 99445)? If 0–1 days, do not bill device codes.
Time Threshold Check:
Is there documented clinical time of 20+ mins (Bill 99457) or 10–19 mins (Bill 99470)?

Interaction Check:
Did a live, two-way interaction (call/video) occur? If not, management codes cannot be billed, regardless of time spent.
Global Period Check:
Is the billing provider in a surgical global period? If yes, hold billing or route to a non-global practitioner.

The RPM Audit Proof Pack

If a payer requests records, you should be able to produce a clean package that answers: why this patient, why this device, why this time, and why this billing unit.

Enrollment artifacts

Established patient proof (initiating visit exists in history).
Medical necessity statement tied to a monitored condition and a treatment plan.
Consent note with date and a short summary of cost sharing and responsibilities.
Device type and provisioning record (what device, when supplied, how connected).

Monthly billing artifacts

Device report showing transmitted days in the billed period.
Management time log with date, duration, and activity entries that sum to the billed threshold.
Interactive communication record: date, mode, and brief summary of what was discussed and what changed.
Monthly summary note: trends, exceptions, actions taken, and the plan going forward.

Internal control: run a quarterly self audit. Randomly sample RPM patients and verify consent, day counts, time logs, and interaction documentation match what was billed.

RPM Frequently Asked Questions

Use this FAQ as a reference when you’re designing or tuning your program. It focuses on how RPM actually works under current Medicare rules.

1

Is RPM only for chronic conditions?

No. Medicare allows RPM for acute or chronic conditions when remote physiologic monitoring is medically necessary and will be used to guide treatment. Chronic conditions (hypertension, heart failure, diabetes, COPD, CKD, etc.) are most common, but short-term acute monitoring can also be appropriate when it truly changes care.

2

Do I always need 16 days of data to bill RPM?

The 16-day rule currently applies to 99453 and 99454 – the setup and device supply codes – which require monitoring over at least 16 days in a 30-day period. It does not apply to 99457/99458, which are purely time-based treatment management codes.

Starting in 2026, 99445 will cover 2–15 days of transmitted data and the existing 99454 will be reserved for 16–30 days. For each 30-day period you pick the single device code (99445 or 99454) that matches the days of data; they are not additive.

3

Can I bill RPM and CCM (or APCM) in the same month?

In many cases, yes – RPM can be billed in the same month as CCM, APCM, or other care-management codes as long as you don’t double-count the same minutes or services.

You cannot bill both RPM and RTM for the same patient in the same period, and you must be able to explain which program covers which work. Within each category you also pick the single code that fits (e.g., 99445 or 99454 for devices; 99470 or 99457 for base management) rather than stacking multiple base codes for the same month. If you can’t clearly separate the minutes, don’t stack the codes.

4

What do patients pay for RPM under Medicare?

RPM is a Part B service, so standard Part B cost-sharing applies: Medicare typically pays 80% of the allowed amount and the patient is responsible for 20% coinsurance, plus any unmet deductible. Medigap or secondary coverage may absorb some or all of that, but you can’t assume RPM is “free.”

Clear, upfront communication about coinsurance is critical to avoid patient surprise bills and reputation damage.

5

How much management time do we really need to track?

For 99457, you must document at least 20 minutes of treatment management time in the calendar month, including interactive communication with the patient or caregiver. From 2026 onward, 99470 gives you a 10-minute management option for lighter-touch months. Each 99458 adds another 20 minutes in the same month when justified.

Time should reflect real work: reviewing data, triaging alerts, adjusting the plan, communicating with the patient, and documenting those decisions. “Rubber-stamping” a dashboard once a month is not defensible.

6

What are auditors actually looking for in RPM programs?

OIG and payers are focused on patterns such as:

Device codes billed month after month with little or no actual data.
No established relationship or obvious medical necessity in the chart.
RPM and RTM billed together for the same patient and period with no clear distinction in services.
Multiple practices billing RPM for the same patient in the same period.
Management codes billed with no credible documentation of time or interaction.

If your documentation can clearly answer “why this patient, why this device, why this amount of time,” you are operating where RPM was intended to be.

7

Is it legal for my vendor to charge a % of my collections?

High Risk. The OIG has issued unfavorable opinions regarding vendor fees calculated as a percentage of reimbursement or "per-patient" fees where the vendor provides redundant services.

These arrangements can be viewed as kickbacks or referral payments. The safest model is a Fair Market Value (FMV) flat fee for technology and support services, regardless of how much you bill.

8

Can we run RPM using only an app or patient entered values?

Not defensibly. RPM requires objective physiologic data collected by an eligible medical device and automatically transmitted. If the workflow is symptom surveys, adherence check ins, or patient entered metrics, that is the conceptual territory of RTM, not RPM.

9

Can we bill 99091 with modern RPM management codes?

Operators typically avoid mixing legacy data review billing with monthly RPM management billing in the same period because it creates overlap risk and complicates audit response. Standardize on one approach per patient and period and keep documentation clean.

10

How do we avoid double counting minutes across RPM and CCM or APCM?

Partition work by intent and log it as separate blocks. If a call is performed to resolve an RPM alert, it belongs to RPM management time. If a call is care coordination unrelated to device driven monitoring, it belongs to CCM or APCM. If you cannot clearly separate the work, do not stack the codes.