What CMS’s New Billing Rules Mean for Chronic Care and Hospital-at-Home Programs
The Centers for Medicare & Medicaid Services (CMS) has made notable updates to how remote monitoring (RPM) services can be reported. These changes could have lasting impacts on healthcare organizations’ service strategies, patient engagement, and program integrity.
To help make sense of these updates, the Validic team spoke with coding, coverage, and payment, policy expert Robert Jarrin, who shared his perspective on how new codes and associated regulations may reshape the RPM ecosystem and what healthcare leaders should consider as they plan their digital health strategies.
From 16 Days Down to 2 Days of Data Collected: A Fundamental Change in Data Reporting
For years, providers offering RPM services were required to collect at least 16 days of patient medical device data within a 30-day period in order to fulfill coding and CMS billing requirements. Under the new coding structure, CPT created new remote physiologic monitoring code 99445, and CMS adopted it, which allows billing for at least two days of medical device data. Interestingly, CMS will be paying 99445 at the same rate as 99454, regardless of the lower days of data monitored threshold.
In Jarrin’s opinion, the new code was meant to better align with the difficult realities of capturing patient engagement, but the payment as finalized by CMS may be a source of concern.
On the positive side, the higher medical device data threshold was a barrier for providers. A lower requirement will help reflect realistic patient adherence allowing care teams that deliver legitimate, high-quality RPM programs to be compensated even patients don’t or unable to produce 16 days of data monitored. This was a particular challenge for providers monitoring patients with acute conditions.
However, this change also raises questions about program integrity or the ability to better understand utilization. The lack of distinction between 2 days and 30 days of data may unintentionally incentivize bad actors and ease their ability to use technology that does not fulfill the requirements of these codes (i.e., a device as defined by FDA).
Healthcare organizations must therefore be diligent to ensure that requirements – namely the use of a medical device as defined by FDA – are used when providing RPM services. Actively regulated devices must follow general controls that include registration, listing, labelling, and may include other requirements such as good manufacturing practices, post-market surveillance, and other standards.
Shorter Work Thresholds: New Flexibility in Treatment Management Services
Another notable development is the introduction of CPT code 99470which lowers the initial time / work requirement from at least 20 minutes to at least 10 minutes of treatment management. CPT code 99470 may be used instead of existing code 99457 which requires at least 20 minutes of treatment management services (i.e., either 99470 or 99457 may be used to reflect initial work, but not both simultaneously). CPT code 99458 remains the same which describes each additional 20-minute increment of work.
This change reflects an acknowledgment of how clinical workflows operate in practice. Providers can now be reimbursed for meaningful engagement that doesn’t always meet the full 20-minute initial window of work, creating more flexibility when patient follow-up and digital monitoring prove challenging in routine care.
Various Challenges Remain
Despite progress in some areas, other aspects of the CMS final rule leave gaps in clarity, particularly around payment for AI and software as a medical device such technologies used for remote therapeutic monitoring (RTM) of cognitive behavioral therapy.
CMS did not acknowledge an important valuation recommendation reached by the Health Care Professionals Advisory Committee (HCPAC) of AMA’s Relative Value Scale Update Committee (RUC). HCPAC recommended that CPT code 98978 which represents the monthly supply of a digital therapeutic medical device, should be added to the CMS direct practice expense of medical supplies with a valuation of $50 per month. CMS did not mention this interesting recommendation in the proposed rule, nor did it acknowledge it in the Final Rule – even though multiple stakeholders had raised the issue during comments.
This omission highlights a broader issue: the lag between innovation in digital medicine and the pace by which CMS regulation has evolved.
Jarrin notes, present day coverage and payment stem largely from CMS’s interpretation of the Social Security Act. Accordingly, CMS has developed payment methodologies which preclude reimbursement for software-as a medical device which by operation of law meet FDA requirements. This interpretation prevents CMS from fully recognizing software as a medical device (SaMD) as the equivalent of traditional medical device equipment practice expenses.
What This Means for Healthcare Leaders
The continual evolution of CPT codes for remote monitoring presents both new opportunities and new responsibilities:
Leverage flexibility responsibly. The ability to bill for shorter monitoring periods can increase program sustainability—but only when paired with clinically validated medical devices and appropriate oversight.
Vet your technology partners. Ensure all solutions used for RPM are true medical devices, compliant with FDA registration, listing, quality, and reporting standards.
Monitor compliance and utilization. Transparent tracking and documentation can help prevent misuse while supporting the sustainable growth of RPM programs.
Advocate for clarity. Engage in public comment periods and industry coalitions to help CMS modernize its interpretation of digital medicine and software as a medical device based care.
Looking Ahead
Remote monitoring has evolved dramatically since its introduction decades ago, and its value has been proven across patient populations and care settings. Utilization surged during COVID-19 in 2020 and continues to grow which is a testament to its importance in modern care delivery.
Still, policy needs to keep pace with these developments. CMS’s willingness to update RPM codes is a positive sign, but healthcare leaders must remain vigilant to ensure these policies lead to better care, smarter reimbursement, and stronger program integrity.
At Validic, we believe the path forward lies in collaboration between regulators, providers, and innovators to build a reimbursement framework that supports both innovation and accountability.