A September 2024 Office of Inspector General (OIG) report found that 43% of Medicare patients enrolled in RPM were not billing for all three components of RPM – device setup (CPT® Code 99453), device supply (CPT® Code 99454), and treatment (CPT® Code 99457 and 99458). OIG concluded that there could be RPM fraud or misuse and that additional Medicare oversight was required.
This conclusion missed the fact that the RPM can improve outcomes and reduce costs even if patients are not meeting the requirements to bill all three codes. A patient with 15 days of reading in a month OR 15 minutes of care time would fall into the 43% referenced in the report.
Medicare Audits for RPM & CCM are Imminent
Auditors will be looking to ensure that practices are meeting the requirements for RPM and CCM. Some of the specific things they could be looking for include:
Time Tracking and Billing Code Requirements: Auditors will be looking to ensure that RPM and CCM time-based requirements are met every time they are billed. In addition, the 16-days of readings requirement must be met for billing CPT® Code 99454. The number of readings and minutes must be clearly document in the provider’s remote care software platform and/or EHR to demonstrate compliance.
Documentation of the “interactive communication” for CPT® Code 99457 is also important as text communication is not sufficient to meet this requirement. Providers must be able to document synchronous, two-way interactions, such as a phone call or video chat. Auditors will also be looking for “upcoding,” where a provider submits for more codes than a diagnosis warrants.
Fraudulent Providers of RPM Services: The OIG report specifically mentions “illegitimate” RPM companies that are providing independent RPM services and directly billing Medicare. Other partnership-based remote care models such as Optimize Health’s, provide clinical care while proactively working with an office’s clinicians, who bill Medicare. While the independent models appear to be a bigger target for investigation, a trusted partner is critical for RPM success.
Documentation of Practitioner Orders: RPM and CCM both require a provider order. Orders need to be clearly documented for the initiation of RPM or CCM services.
Patient Consent Requirements: Medicare does allow verbal consent for RPM and CCM, but it must be documented in the patient’s medical record. To fully cover the consent requirement, verbal consent should include details such as disclosure of potential copays and the patient’s right to end services at any time.
Justification of Medical Necessity: Documentation must include explicit medical necessity and how RPM or CCM will support the patient’s care.
Qualifications of Monitoring Staff: Clinical staff providing RPM and CCM services must be licensed in the patient’s state and working within their scope of practice. In many states, medical assistants and health coaches do not qualify as clinical staff for billing purposes.
Who is at Risk for an Audit
Audits can be random, but they’re often triggered by unusual billing patterns—such as a high number of CPT® Code 99454 claims without many CPT® Code 99457 claims or vice versa. Looking at your history of billing to see if you have this type of discrepancy can help highlight additional risk for an audit.
Even if you are low risk, it makes sense to clean up your documentation before the OIG audits start so you are well prepared for an audit if it does happen. Ensure your remote care system and/or EHR have clear documentation of orders, medical necessity, and patient consent.
If you do not have a reliable software system to track time and specific billing requirements like synchronous communication, now is the time to invest in one. Lack of proper documentation or billing mistakes can escalate into a formal investigation, leading to financial penalties—or worse.
How Clinical Monitoring Services Can Reduce Audit Stress
Even the best-intentioned practices can find compliance challenging. The right remote care platform and documentation are critical, but with limited resources, it’s still up to clinicians to find the time to document care appropriately.
Partnering with the right remote care company to provide clinical monitoring pushes a significant portion of the compliance burden to experts who know exactly how to ensure compliance. Clinicians that are dedicated to remote care all day, every day have in-depth knowledge of the billing code requirements and can ensure that they are consistently documented correctly.
Is Your RPM Provider Audit-Ready?
Audits can be stressful, but they don’t have to be. Download our 2025 Remote Care Billing Guide to understand compliance requirements. If you aren’t confident that your remote care platform has the functionality to help with an audit or want to explore clinical monitoring services to make compliance easier, set up a free consultation with one of our remote care experts.