The biggest change to RPM reimbursement in years – updates to the RPM 16-day rule

RPM companies, physician practices, medical device manufacturers, and other players in the RPM space have been encouraging the American Medical Association (AMA) CPT® Editorial Panel to reconsider the 16-day rule for Current Procedural Terminology (CPT®) Code 99454 for years. And while there have been indications several times that the AMA was considering changes to the code set, they have declined to make changes until now. The decision to add a new CPT® Code for 2-15 readings a month has already been applauded by many in the industry.

The rationale for the 16-day rule

The intent of the 16-day rule was to ensure provider and patient engagement with remote patient monitoring (RPM). While clinical studies have consistently demonstrated that RPM improves outcomes and lowers costs, it’s only effective if patients are taking sufficient readings for monitoring clinicians to provide proactive, preventative care.

Clearly, a patient who takes their first reading during an in-office appointment and then brings a device home and never uses it will not see the value of RPM. The AMA’s intent in choosing 16 readings every 30 days as a requirement for billing CPT® Code 99454 was likely to ensure sufficient data was collected to have a positive impact.

The challenges with the 16-day rule

Determining a minimum number of readings per month across all patients and conditions was a decision that many clinicians considered arbitrary. For example, diabetic patients with glucometers typically need at least daily readings to track blood sugar, but a patient who is morbidly obesity and using a scale to track weight loss may only need 1-2 readings per week. The 16-day rule inherently limited the number and type of patients and conditions that could be effectively monitored with RPM.

And even for patients that would benefit from daily or every other day readings, clinicians could still provide valuable, proactive care with 14 or 15 readings per month or even less.

The 16-day rule also provided confusion amongst providers that limited the adoption of this potentially life-saving technology. It was difficult for a medical group to know what percentage of their patients that could benefit from RPM would actually meet the billing thresholds. Given this uncertainty and the time and money required to launch a new RPM program, many practices opted to not implement RPM despite the clinical benefits. 

The AMA review process for CPT® Code changes 

The AMA uses an open process to determine changes to Current Procedural Terminology (CPT®) codes. The CPT® Editorial Panel is an independent group of volunteers that reviews and maintains CPT® code set, including applications for new or revised codes. 

The panel of 21 members meets at least three times per year and is authorized by AMA Board of Trustees to revise, update, or modify CPT® codes, descriptors, rules, and guidelines. Typically, the panel addresses over 200 major topics a year.

The Editorial Panel collects input from practicing physicians, medical device manufacturers, diagnostic test developers, and CPT® advisors who work with industry stakeholders and medical societies.

Specific requests for changes to the codes can be submitted to the AMA.  Medical  societies, physicians, hospitals, third-party payers and other interested parties can make CPT® code change requests. The AMA’s CPT® staff reviews and responds to all requests. If the request presents a new issue or significant new information, it is referred to the CPT® Advisory Committee.

Each agenda item during a meeting is documented and results in one of the following panel actions:

1. Adding a new code or revising the existing description of a code
2. Referring the issue to a workgroup for further study
3. Postponing a decision to a future meeting to collect additional information
4. Rejecting the request 

The AMA review process for the 16-day rule

A review of the RPM CPT® Codes was scheduled for the February 2024 CPT® Editorial Panel meeting, but the agenda item was removed shortly before the meeting. The assumption was that the panel wanted time to collect more feedback before discussing it.

At the May 2024 meeting, the CPT® Editorial Panel considered adding a new RPM CPT® Code that would reimburse providers for patients taking 2- 15 days of readings, presumably at a lower rate than the existing code for 16 or more readings. Despite significant feedback that the 16-day rule provided challenges for providers and patients and limited the ability of RPM to improve outcomes and reduce costs, the panel did not reach the consensus required to make any changes. Ultimately, this led to postponing the decision and drew significant criticism from the industry.

At the September 2024 CPT® Editorial Panel, the committee approved the changes that the industry has advocated for.

The new RPM changes are significant

The proposed changes which will go into effect in January of 2026 are very significant and include:

1. A new code will cover 2 to 15 days of readings within 30 days. This means that providers will be reimbursed for patients who take less than 16 days of readings.
2. CPT® 99457 which currently requires a minimum of 20 minutes of care management time will be revised to include 11-20 minutes of care management.
3. CPT® 99458 which currently covers additional care management time in 20-minute increments will now cover additional 10 minutes increments.

What do the new RPM CPT® Code changes for RPM companies and providers?

These changes should lead to a significant expansion of RPM services for practices and hospitals. Providers will be able to earn more reimbursement for RPM for a wider range of conditions and provide more proactive care to more patients. 

The final reimbursement rates are still unknown, but it’s reasonable to expect a lower reimbursement rate for fewer readings. However, the potential pool of patients that could benefit from RPM will be larger. Whether a patient is taking a few readings a month or daily readings, onboarding, adherence and retention are still critical for clinical and financial success. This means practices need easy-to-use, affordable, high-quality devices that encourage active participation in the program but still work with potentially lower reimbursement rates. 

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