Sweet 16 No More: AMA’s New Billing Flexibility for Remote Physiologic Monitoring (RPM)
The American Medical Association (AMA) recently announced a significant change to its billing policy for Remote Physiologic Monitoring (RPM). Starting in January 2026, the AMA will eliminate the requirement for patients to transmit RPM data for 16 out of 30 days to qualify for provider reimbursement. This decision removes a barrier that has hindered RPM’s practical application and aligns more closely with how providers and patients actually use RPM technology.
To understand why this change matters, let’s delve into the background of RPM coding, the challenges that providers have faced, and how this decision may shape the future of remote healthcare.
The Evolution and Challenges of RPM Coding
Remote Physiologic Monitoring (RPM) has long been recognized as an innovative way for healthcare providers to remotely track and monitor patients' health data, such as blood pressure, weight, or glucose levels. Over time, the Centers for Medicare & Medicaid Services (CMS) and the AMA introduced specific CPT codes to reimburse providers for RPM services. These codes, intended to support providers in monitoring patients with chronic conditions and managing treatment remotely, initially provided hope that the healthcare industry was advancing towards a more efficient and accessible care model.
However, to bill for RPM services, the AMA required patients to submit data at least 16 days out of a 30-day period—a requirement often viewed as excessively stringent and unrealistic. While the requirement aimed to ensure quality and accountability, it placed a significant burden on both providers and patients. Patients often struggled to submit RPM data consistently, while providers found themselves unable to qualify for reimbursement due to noncompliance with the rigid 16-day threshold.
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For many providers, this threshold became a costly barrier. Without the ability to guarantee 16 days of data transmission, healthcare providers could not reliably bill for the RPM device supply code. This problem was exacerbated by the fact that providers have little control over patients’ adherence to data collection. Even when high-quality monitoring was achieved with less frequent reporting, the 16-day rule prevented providers from receiving full reimbursement for their services, contributing to industry frustration and limiting RPM's potential impact on patient care.
A report by the CMS (2024) noted that many providers struggled to meet this standard, leading to frequent denials of reimbursement. For example, with RPM codes 99453 and 99454, reimbursement was only possible if the patient submitted data more than half the days in a month—a high bar, considering that patients must conduct data collection on their own, such as by stepping on a connected weight scale or using a connected blood pressure monitor.
“The collection of 16 days of data was not always clinically necessary…”
The frustration with this requirement has been well-documented, with providers arguing that collecting 16 days of data is not always clinically necessary. They expressed concerns that this rigid benchmark could even be counterproductive, diverting resources from truly necessary care (American Medical Association [AMA], 2024).
Legislative Setbacks and Ongoing Industry Frustrations
Despite strong advocacy for change, RPM legislation has been met with obstacles over the years. In September 2024, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report suggesting potential fraud in RPM billing practices. The OIG expressed concern over instances where RPM codes were not billed concurrently with a “family of codes” and claimed that nearly 43% of RPM enrollees did not receive all RPM components, raising questions about correct usage (HHS OIG, 2024).
Adding to the issue, the CY2024 Medicare Physician Fee Schedule initially mischaracterized the data requirements for RPM codes, incorrectly stating that several codes required 16 days of data to bill (CMS, 2024). This error heightened industry confusion, illustrating the disconnect between regulatory agencies and clinical practice needs.
The industry has pushed back, highlighting that the 16-day threshold was an arbitrary metric. Research indicates that excessive data reporting may not correlate with better outcomes for chronic conditions. The requirement also increased operational costs for providers, who had to follow up with patients for the sake of reimbursement rather than clinical benefit (Peterson Health Technology Institute, 2024).
Recent AMA Decision: What’s Changing?
In response to persistent calls for change, the AMA’s CPT Editorial Panel convened in Washington, D.C., on September 25–28, 2024, and voted to remove the 16-day requirement. This decision will take effect in January 2026, allowing providers to bill for RPM device supply codes without the strict data submission requirement. This move is a breakthrough for RPM stakeholders, offering greater flexibility for billing and enhancing the accessibility of remote healthcare for patients.
Effective January 2026, the 16-day requirement for RPM will expire, allowing providers to bill for RPM device supply codes without unnecessarily strict requirements.
The removal of the 16-day requirement reflects a better understanding of RPM’s real-world application, allowing providers to receive fair compensation for monitoring patients in ways that are clinically meaningful but do not necessitate daily data transmission. This change also opens the door for greater flexibility, enabling providers to customize monitoring schedules based on each patient's needs rather than a one-size-fits-all billing requirement.
The AMA’s valuation committee, the Relative Value Scale Update Committee (RUC), will reevaluate pricing for RPM codes in January 2025. Industry experts predict a slight decrease in reimbursement rates due to the lower reporting burden. Nevertheless, this change is expected to reduce RPM costs and increase adoption by removing what many consider an unfair barrier to RPM billing (AMA, 2024).
Future Implications and Remaining Challenges
The AMA’s decision to remove the 16-day reporting threshold offers promise for the future of RPM. It acknowledges the limitations of the initial requirement and opens the door for RPM to become a more flexible, accessible, and impactful part of healthcare delivery. For patients, this change means they are less likely to face lapses in remote care due to incomplete data submissions. For providers, it means an opportunity to grow RPM services and integrate these technologies into routine care without the fear of uncompensated services.
That said, challenges remain. The OIG and other regulatory bodies may continue to scrutinize RPM billing practices, especially as RPM services expand. The industry will need to demonstrate that the new billing flexibility leads to improved patient outcomes without inviting misuse or fraud. Success will require clear guidelines, consistent communication, and continued collaboration between providers, regulatory agencies, and policymakers.
Conclusion
The AMA’s decision to ease the 16-day data requirement is a win for the RPM industry, paving the way for a more flexible, patient-centric approach to remote care. This change not only addresses years of industry frustrations but also sets the stage for RPM to become an integral part of healthcare for a broader range of patients.
With ongoing advancements in telehealth and RPM technology, the future looks promising for remote monitoring—so long as the industry continues to advocate for sustainable, fair, and accessible practices that serve both patients and providers.
References
American Medical Association. (2024). CPT Editorial Panel Actions on RPM Codes. Washington, D.C.: AMA, https://www.ama-assn.org/system/files/sept-2024-summary-of-panel-actions.pdf
Centers for Medicare & Medicaid Services. (2024). Medicare Physician Fee Schedule for CY2024. Retrieved from CMS.
Department of Health and Human Services Office of Inspector General. (2024). Remote Monitoring Billing Report, https://oig.hhs.gov/reports/all/2024/additional-oversight-of-remote-patient-monitoring-in-medicare-is-needed/