Policy Updates
RPM and RTM Clarifications
From billing clarifications to expanded access for clinics, here's what providers need to know—plus fraud risks flagged by the OIG.
On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized the 2024 Physician Fee Schedule Final Rule, updating policies for RPM and RTM under Medicare. This rule refines billing requirements, resolves stakeholder questions, and builds on prior guidance while rejecting some 2024 Proposed Rule ideas.
Below, we unpack the key 2024 changes for RPM and RTM providers, paired with fraud and risk insights from the HHS Office of Inspector General (OIG) report (September 2024) to ensure compliance and audit readiness.
Patient Eligibility
RPM Limited to Established Patients
RPM remains restricted to "established patients"—those with a prior Evaluation and Management (E/M) visit or similar service establishing a treatment plan. Post-PHE (May 2023), this rule resumed, but the 2024 Final Rule "grandfathers" in PHE-era RPM patients as established, even without an initial exam. New patients after May 11, 2023, must complete this step first.
OIG Alert:
The OIG found 44% of 2022 RPM enrollees lacked ordering provider data, risking fraud if medical necessity isn't verifiable. Document patient relationships and ordering providers to avoid audit trouble.
RTM Flexibility
No "Established Patient" Rule for RTM—Yet
Unlike RPM, RTM lacks an explicit "established patient" requirement in 2024. CMS clarified: "RPM, not RTM, services require an established patient relationship post-PHE." Still, CMS assumes RTM follows an initial evaluation and plan. Skipping this might invite audits under the "reasonable and necessary" standard, with more guidance promised.
Tip:
Proactively establish RTM patient relationships to align with RPM practices and preempt OIG concerns (e.g., 43% of RPM enrollees missing components).
Data Collection
16-Day Data Rule Clarified
The 2024 Final Rule specifies which codes require 16 days of data collection and which don't.
Requires 16+ Days
- •RPM setup (CPT 99453)
- •RPM device supply (CPT 99454)
- •RTM respiratory device (CPT 98976)
- •RTM musculoskeletal device (CPT 98977)
- •RTM cognitive behavioral device (CPT 98978)
No 16-Day Requirement
- •RPM management (CPT 99457)
- •RPM additional time (CPT 99458)
- •RTM management (CPT 98980)
- •RTM additional time (CPT 98981)
OIG Warning:
23% of 2022 RPM enrollees lacked device supply claims, hinting at fraud if data isn't collected as billed. Ensure 16-day compliance where needed to stay audit-safe.
Billing Limits
One Practitioner, One Bill
Only one practitioner can bill RPM (CPT 99453, 99454) or RTM (CPT 98976, 98977, 98980, 98981) per patient per 30-day period, requiring 16 days of data from one device—even with multiple devices. CMS didn't address if multiple practitioners can bill treatment codes (99457, 99458) together; clarification is needed. Overbilling risks audits.
OIG Red Flag:
A provider billed 23,569 hours of RPM in 2022—beyond human capacity. "Incident-to" billing obscurity heightens fraud risks. Stick to single-practitioner rules with clear records.
Service Pairings
Pair RPM/RTM with Other Care
Bill RPM or RTM (not both) with other care management services—no double-counting time. This balances flexibility and fraud prevention.
Can Pair With:
- Chronic Care Management (CCM)
- Transitional Care Management (TCM)
- Behavioral Health Integration (BHI)
Also Compatible With:
- Principal Care Management (PCM)
- Chronic Pain Management (CPM)
Cannot Pair:
- RTM codes 98980/98981 with RPM codes 99457/99458
- Any service with overlapping time
OIG Note:
12% of RPM enrollees missed treatment management, suggesting fraud if billed without delivery. Track services meticulously to prove compliance.
Surgical Billing
Global Surgery Billing Rules
The 2024 clarification addresses how RPM/RTM interacts with global surgery payments.
Global Surgery Providers
Practitioners on global surgery payments can't bill RPM/RTM during that period—it's included in the lump sum.
Non-Global Practitioners
Therapists and other non-global practitioners can bill if unrelated to the surgery's diagnosis, addressing a separate care episode.
Documentation Requirements
Clear documentation of distinct conditions is essential for separate billing.
OIG Insight:
Vague diagnoses (e.g., 7,000+ enrollees billed for "other specified counseling") raise fraud flags. Document distinct conditions clearly for separate billing.
Clinic Updates
FQHCs and RHCs Get Separate Pay
Starting January 1, 2024, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can bill RPM/RTM separately using HCPCS G0511, if reasonable, necessary, and non-duplicative. Multiple monthly bills are allowed if costs aren't overlapped. Rates will be posted on RHC and FQHC websites.
OIG Context:
RPM payments hit $311 million in 2022. With growth comes scrutiny—ensure accurate billing to avoid fraud allegations.
Therapist Rules
General Supervision for RTM Assistants
From January 1, 2024, physical and occupational therapists in private practice (PTPPs/OTPPs) can bill RTM for assistants (PTAs/OTAs) under general supervision, not direct, per new regs (42 C.F.R. § 410.59, 410.60). Direct supervision applies if the PT/OT isn't Medicare-enrolled.
OIG Takeaway:
Inadequate staffing in RPM firms risks fraud. Document supervision to prove RTM legitimacy.
MSSP Scope
RPM Excluded from MSSP Primary Care
CMS chose not to add RPM codes 99457 and 99458 to Medicare Shared Savings Program (MSSP) primary care definitions in 2024. Specialists can bill these, potentially skewing assignments, so they're excluded.
OIG Lens:
1 in 10 enrollees used RPM-specialized firms, underscoring role clarity to prevent billing conflicts and fraud.
Next Steps
Conclusion: Navigate 2024 with Caution
The 2024 Final Rule brings important changes to RPM and RTM billing.
Key Improvements
The 2024 Final Rule sharpens RPM and RTM billing, introducing flexibility like FQHC/RHC payments and supervision changes.
Remaining Gaps
Questions remain about multiple practitioners billing treatment codes and other nuances that need future clarification.
OIG Scrutiny
The OIG's 2022 data—570,000 RPM enrollees, $311 million paid, and risks like cold-calling schemes—highlight fraud vulnerabilities.
Future Outlook
Providers should engage in future rulemaking to refine these rules, ensuring quality care while dodging audit pitfalls.