Billing RPM Under Capitation Agreements

Navigate the complexities of Remote Patient Monitoring billing in capitated payment models

Remote Patient Monitoring codes – 99453, 99454, 99457, and 99458 – are normally payable under Medicare's fee-for-service schedule. However, in capitated arrangements or managed care plans (like Medicare Advantage), these services are often considered part of the provider's overall payment. This can lead to CO-24 denials (claim adjustment code 24: "charges are covered under a capitation agreement or managed care plan") when billing RPM separately.

Below is a comprehensive guide on how Medicare (and Medicare Advantage) handle RPM billing under capitation, and strategies for providers in such situations.

Understanding Coverage Models

Traditional Medicare vs. Medicare Advantage

Traditional Medicare (Fee-for-Service)

RPM services are covered and reimbursed separately under Original Medicare (Part B)
CMS created these codes to pay providers for setting up devices, supplying equipment, and managing patients remotely
You can bill 99453, 99454, 99457, 99458 to Medicare and receive payment according to the Physician Fee Schedule
There is no "capitation" in standard Part B – each service is paid fee-for-service

Medicare Advantage (Part C) and Managed Care

MA plans must cover all Part A and B services, including RPM, but they pay providers according to their own contracts
Many MA plans use capitated payment models where the provider gets a fixed monthly payment per patient
RPM services are typically considered included in that capitation payment, not paid separately
Claims often come back with denial code CO-24, indicating the charges are covered under the capitation agreement

Carve-Outs and Exceptions

Not all managed care contracts are the same. Some plans carve out certain services from capitation.
RPM codes, however, have generally not been carved out by default – most plans treat them as part of routine care.
CMS has not mandated separate payment for RPM under MA; it leaves it to the plan.
Always check your participation agreement or the plan's provider manual to see if RPM is listed as separately billable.

Special Case: RHCs/FQHCs

CMS recently created a carve-out for RHCs/FQHCs in 2024, allowing them to bill RPM/RTM using code G0511 (a general care management code) for separate reimbursement. This exception shows that typically bundled payment systems can carve out RPM if policy-makers choose – but in most cases, without a specific carve-out, RPM is bundled into capitation.

Optimizing Your Approach

Best Practices for Billing RPM Under Capitated Plans

If you provide RPM services to patients in a capitated plan (e.g., an MA HMO), use these best practices to navigate billing:

Verify Insurance and Plan Type Up Front

Always check if the patient is enrolled in a Medicare Advantage or managed care plan before billing RPM. If the patient has an MA plan, identify whether you (the provider) are contracted on a capitated basis. If you mistakenly submit an RPM claim to Original Medicare for an MA enrollee, it will be denied as not covered by Medicare (CO-24) – you need to bill the MA plan instead.

Review Your Contract for Carve-Outs

Consult your managed care contract or provider handbook to see which services are included in the capitation. If RPM services (99453-99458) are not listed, or if the contract has a section for "Care Management fee-for-service payments," there may be room to bill for them. Getting written clarification can save you from repeated denials.

Avoid Unnecessary Claim Submissions

If you know a plan considers RPM part of capitation (and will deny it), you might choose not to bill those codes at all to avoid CO-24 denials. Unpaid denied claims create extra work and do not generate revenue. Instead, document the RPM services internally to demonstrate the care you provided.

Bill Correctly if You Do Bill

When submitting RPM claims to a payer that will pay separately, ensure all Medicare requirements are met. For example, use the correct place of service (POS) on the claim. RPM codes are not traditional telehealth services that require the telehealth POS – CMS considers them care management services provided remotely.

Communication with the Plan

Don't hesitate to reach out to the plan's provider relations or billing support. Ask explicitly: "Are CPT 99453, 99454, 99457, 99458 payable outside of capitation for our contract?" Getting an answer in writing (email or policy document) is ideal. If the plan is silent on RPM in policies, assume it's bundled, but consider formally requesting a policy clarification.

Addressing Challenges

Handling CO-24 Denials and Appeals

Despite precautions, you may still receive CO-24 denials for RPM codes. Here's how to address them:

Double-Check Eligibility

First, confirm that the denial is truly due to capitation and not a mistake. CO-24 on a Medicare remittance usually means the patient has an MA plan or similar. Ensure you billed the correct insurer. If you accidentally sent the claim to Medicare for an MA patient, you'll need to resubmit it to the MA plan.

Assess the Contractual Status

Review the patient's plan and your contract. Was the patient attributed to you as a capitated primary care provider at the time of service? If you are not the capitated provider (for example, you're a specialist or third-party RPM provider without a capitation agreement), you might have grounds to appeal.

Determine if an Appeal is Warranted

If the denial was correctly applied per the contract (i.e., the service is included in your capitation), an appeal is unlikely to overturn it. Appeals succeed only if something was done in error – for example, if the plan's system denied it but your contract actually lists RPM as payable separately.

Medical Necessity Angle (Rarely Succeeds)

You can try to argue that the RPM was a medically necessary, distinct service that merits separate payment, but if the contract says you're prepaid for "all covered services," the plan will counter that you've already been paid via capitation. Don't expect a simple medical necessity appeal to trump a capitation rule.

Follow Through

If you do appeal, send all required info and track the timeline. Many appeals for capitated denials are upheld with a generic response ("service included in capitation per contract"). At that point, you may have to write it off. Instead, focus on prospective solutions (e.g., negotiating a carve-out going forward).

Remember: A CO-24 denial itself typically indicates the payer's final stance per the contract, so use appeals mainly to correct misrouted or miscategorized claims. For true contractual non-payment, direct negotiation or alternative billing is more effective than the formal appeal process.

Finding Solutions

Alternative Billing Strategies if RPM Isn't Separately Reimbursable

If you find that you cannot get paid for RPM services under a capitation model, consider these alternative paths:

Chronic Care Management (CCM) Services

Patients who qualify for RPM often have chronic conditions that would qualify them for Chronic Care Management (CCM) under Medicare. CCM CPT codes like 99490 (20 minutes of clinical staff time per month for care coordination for patients with 2+ chronic conditions) and add-on 99439, or complex CCM codes (99487/99489), are payable by Medicare and many MA plans.

Medicare allows RPM and CCM to be billed in the same month for the same patient as long as you don't double-count the time or work (you must allocate distinct time to each service).

Transitional Care Management (TCM)

If your RPM is primarily around patients recently discharged from a hospital or skilled nursing facility, consider billing TCM codes (99495, 99496) after those discharges. TCM involves a post-discharge interactive contact within 2 business days, plus an office visit within 7 or 14 days and medication management and care coordination in between.

Note: You cannot bill RPM 99457 in the same calendar month as TCM for the same patient because Medicare does not allow overlapping TCM and RPM in the same service period.

Principal Care Management (PCM)

Medicare now offers Principal Care Management codes (e.g., 99424, 99425) for patients with a single high-risk condition. If your RPM program is focused on one condition (say, hypertension or CHF management via monitoring), PCM is another avenue. It's similar to CCM but for patients with one complex chronic condition.

Annual Wellness Visits (AWV) and Preventive Services

While not a direct substitute for RPM, conducting an Annual Wellness Visit (G0438/G0439) or other preventive visits can help capture some compensation for time spent on a patient's care plan. AWVs are separately paid by all Medicare plans (no cost-sharing to patient) and allow time to set up a personalized prevention plan.

Value-Based Payments and Incentives

In capitated or managed care environments, the financial reward for RPM might come indirectly. For example, many Medicare Advantage contracts offer performance bonuses or shared savings based on quality measures (BP control, diabetes control, reduced admissions). RPM can be a tool to achieve these outcomes.

You may be able to negotiate an additional per-member-per-month care coordination fee or a higher capitation rate for patients enrolled in RPM, by showing that it adds value.

Key Insight: When shifting strategies, remember that Medicare allows you to legitimately perform RPM (e.g., device monitoring) and also bill CCM in a month, if you separate the work. It gives you flexibility to combine programs to get some reimbursement. Ensure your documentation clearly delineates which minutes were spent on what activity.

Authoritative Resources

Official Guidance and References

When navigating RPM billing under capitation, it helps to reference official sources:

CMS and MAC Guidance

Medicare Administrative Contractors have issued reminders that if a patient is in a Medicare Advantage plan, claims must be sent to that plan, not Medicare, and any services covered by the plan's capitation won't be paid separately. A CO-24 denial from Medicare means "bill the MA plan or risk-bearing entity instead" – Medicare's fee-for-service system won't pay you.

CMS FAQ on Capitated RPM

In a CMS telehealth Q&A compendium, CMS addressed whether a provider could bill 99453, 99454, 99457 for a "full risk and capitated" Medicare beneficiary. CMS's response was that those codes are not on the telehealth list and that specific coverage and payment for a capitated Medicare Advantage patient should be discussed with the MA plan. This is a clear acknowledgement from CMS that RPM billing in Medicare Advantage is governed by plan policy, not a national rule.

Medicare Policy Statements

CMS has categorized RPM codes 99457/99458 as care management services, not as telehealth visits. For example, CMS's Medicare Learning Network and rulemaking commentary note that these services can be provided under general supervision and are meant to be monthly care management activities.

Concurrent Billing Rules

Official CMS guidance confirms that RPM services may be billed in the same time period as other care management services like CCM or TCM as long as the time/effort isn't counted twice. This is important when shifting strategies – it means you can legitimately perform RPM and also bill CCM in a month, if you separate the work.

OIG and Oversight Reports

The HHS Office of Inspector General (OIG) has been examining RPM usage and payments in both Traditional Medicare and MA. An OIG report in 2022 found growing use of RPM and suggested Medicare ensure appropriate oversight. While this doesn't directly change billing, it signals that Medicare Advantage plans are reporting RPM (in encounter data) even if not paying fee-for-service, and regulators are watching.

Summary:

Most RPM billing hurdles under capitation come down to contract and plan policy rather than Medicare rules. Traditional Medicare will pay for these codes, but if you operate in a capitated model (Medicare Advantage or similar), you must align with how that model handles them. Best practice is to proactively manage your patient population with RPM for the clinical benefits, but also proactively manage your revenue by knowing which payers will reimburse it, appealing when appropriate, and finding alternative billing for your work when they won't.

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