Revenue Cycle Insider

Pay attention to your documentation when billing RPM.

Healthcare practitioners often use remote patient monitoring (RPM) as a method to effectively oversee the health status of their patients without the need for regular face-to-face appointments. Despite the potential benefits and advancements of RPM for both caregivers and their patients, there are a number of obstacles that can cause issues down the line.

Read on to get expert advice on RPM coding from Monica Wright, DPA, MHA, CPC, CPMA, CPCO, during the DOCUCON 2025 presentation, “Remote Care, Real Risk: Documenting Remote Patient Management.”

Learn the Different Types of RPM

There are two types of RPM as defined by the U.S. Department of Health and Human Services (HHS):

• Remote physiological monitoring refers to the application of technology that doesn’t require in-person interaction to observe and evaluate a patient’s physiological measurements. These measurements can include elements such as blood pressure, glucose, or oxygen levels in the blood, and fluctuations in weight.

• Remote therapeutic monitoring (RTM) captures non-physiologic data related to a therapeutic treatment. This includes data on a patient’s musculoskeletal or respiratory system. RTM can also monitor a patient’s adherence to their treatment and their response to that treatment. This information is then transmitted electronically via a connected medical device.

“RPM consists of three main components, each building off the step before it,” said Wright.

To bill for RPM, you have to document all three of the following:

1. Patient education and device setup: This includes showing the patient how to use the device and how to accurately collect the data (if applicable).
2. Device supply: This includes choosing the best device for the patient, connecting the device so the practitioner can read results, and educating the patient on how often they should be using the device.
3. Treatment management: This involves reviewing patient data to improve patient health outcomes.

Review These Codes for Remote Physiological Monitoring

The following codes are what you will refer to when billing for RPM services:

• 99453 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate); initial set-up and patient education on use of equipment)
• 99454 (… device(s) supply with daily recording(s) or programmed alert(s) transmission, 16-30 days in a 30-day period)
• 99473 (Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration)
• 99474 (… separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient)

Coding tips: Report 99453 for each episode of care. You should not report 99473 on the same day as any other evaluation and management (E/M) service. You shouldn’t use 99474 more than once per calendar month.

“One thing to know about these services, they are found in the [E/M] section of the code book. This is important because it determines who can bill these services,” said Wright.

When billing these codes on a claim, it’s important to include the following:

• Physician’s or other qualified healthcare professional’s order
• Patient consent
• Description of the device
• Initial device setup details
• Education/instruction on the use of the device
• Patient transmission of data for at least 16 days

“Some things to be aware of when you’re looking at this code set is not all of these things are necessarily going to be found in one record of the chart,” said Wright. “If someone asks you to pull records for the physiologic monitoring, is that order part of your note? Probably not. If it came from someone outside of your practice, then you’ve got to be able to find that order. The patient consent has to be obvious,” Wright added.

Review These Codes for Remote Therapeutic Monitoring

The following codes are what you will refer to when billing for RTM services:

• 98975 (Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); initial set-up and patient education on use of equipment)
• 98976 (… device(s) supply for data access or data transmissions to support monitoring of respiratory system, 16-30 days in a 30-day period)
• 98977 (… device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 16-30 days in a 30-day period)
• 98978 (… device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 2-15 days in a 30-day period)
• 98980 (Remote therapeutic monitoring treatment management services, physician, or other qualified health care professional time in a calendar month requiring at least 1 real-time interactive communication with the patient or caregiver during the calendar month; first 20 minutes)
• 98981 (… each additional 20 minutes (List separately in addition to code for primary procedure)

Coding tip: You can report 98975 after each episode of care.

For codes 98980 and 98981, the full 20 minutes is required to bill the service and the full 20 minutes applies to both codes. This time must be spent exclusively (without overlap) from any other care management services performed in the same month. “You must bill a full 40 minutes to bill both 98980 and 98981, and do not count any time related to any other services,” Wright said.

When billing for RTM on a claim, it’s important to include the following:

• Physician’s order
• Description of device being used (if applicable)
• Review of data collected
• Assessment of symptoms/patient adherence
• Adjustments of treatment plan
• Summary of patient interaction (phone call, in-person visit)
• Care coordination
• Time spent with patient

According to Wright, the major similarities between billing for RPM and RTM codes are time spent outside of E/M services, clinical staff time can be counted, and they are billed monthly.

The primary differences between the two are that RTM does not require you to capture a device, and they are mostly used for care coordination. RTM differs from RPM in that the patient can offer a handwritten note to communicate how they are progressing in their therapy; whereas with RPM, the data must come directly from the device transmission.

“These are not E/M codes, so physical therapists, respiratory therapists, and occupational therapists can bill for these codes,” she said.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC