📦 New RPM Codes Mean More Flexibility—and More Reimbursement

For years, one of the most limiting rules in RPM billing has been the “16-day rule”, which required providers to capture at least 16 days of readings per month to bill CPT 99454. This meant that patients with lighter monitoring needs (e.g., checking vitals 1–2x/week) couldn’t be billed at all.
That’s changing in 2026.

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🆕 Meet CPT 99XX4 and 99XX5
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• CPT 99XX4 — For device supply and monitoring when a patient captures just 2 to 15 days of data in a 30-day period.
  💰 Reimburses at $44.45, the same as 99454.
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• CPT 99XX5 — For 10 to 20 minutes of care management time in a calendar month, including at least one live interaction with the patient.
  💰 Reimburses at $25.73, or roughly half of 99457’s value.

In other words:

• You can now bill either 99454 (16+ days) or 99XX4 (2–15 days) in each 30-day period.
• You can bill either 99457 (20+ minutes) or 99XX5 (10–20 minutes) per calendar month.

These changes also apply to Remote Therapeutic Monitoring (RTM), giving your care team greater flexibility across programs.

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💡 Real-World Revenue Impact: A 13% Increase

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An example from a 522-patient RPM program in New York helps illustrate what this means in practice:
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• In 2025, patients who didn’t hit the 16-day threshold brought in $0.
• In 2026, those same patients (83 of them) will contribute $44.45 each with 99XX4.
• Brief check-ins (10–20 minutes) that previously weren’t billable will now bring in $25.73 each.
  

📈 Result: The program saw revenue jump from $42,445/month to $47,833/month — an annual increase of nearly $65,000. That’s without adding a single patient.

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⚖️ CMS vs. AMA: A Reimbursement Rift

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Behind the scenes, CMS and the American Medical Association (AMA) disagree on how to value these new codes:
The AMA wanted 99457 to start at 11 minutes and for 99458 to stack in 10-minute increments.

CMS rejected this and instead used hospital outpatient (OPPS) data to value 99XX4, 99XX5, and even 99457.
CMS cited insufficient RUC survey data and stated that final valuation will likely be revisited in 2028.

So while the reimbursement is helpful, it's still in flux—and practices should monitor future updates.

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📹 Virtual Direct Supervision Goes Permanent

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CMS has proposed to permanently adopt virtual direct supervision using real-time audio/video. This applies broadly:

• Includes all incident-to services (except high-risk surgical codes with global periods of 010 or 090)
• Extends to FQHCs and RHCs
• Providers have discretion to choose in-person or virtual based on clinical appropriateness

🚀 This is a major win for staffing flexibility—especially for organizations supporting multiple locations or using centralized clinical teams.

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🏥 FQHCs and RHCs: G0511 Is Going Away

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The long-used G0511 code will be fully retired as of September 30, 2025. This impacts Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) that previously relied on G0511 to bill for:
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• Remote Patient Monitoring (RPM)
• Remote Therapeutic Monitoring (RTM)
• Chronic Care Management (CCM)
• Behavioral Health Integration (BHI)
• Principal Care Management (PCM)
  

Going forward, these providers must transition to standard CPT codes. Start preparing now to ensure billing continuity and avoid revenue disruption.
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🧠 APCM Updates: New Add-On Codes + Preventive Care Integration

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For practices using Advanced Primary Care Management (APCM), CMS is proposing new add-on codes that allow BHI and CoCM services to be billed in tandem:
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• GPCM1 – Initial psychiatric collaborative care (first month)
• GPCM2 – Subsequent months of collaborative care
• GPCM3 – Non-time-based behavioral health care management under physician oversight

Unlike traditional BHI/CoCM codes, these are not time-based, making them easier to implement.
CMS is also exploring:

• Whether to bundle preventive services (like Annual Wellness Visits or depression screening) into APCM
• Whether to eliminate cost-sharing when APCM includes prevention

This could be a step toward simplified, more inclusive primary care reimbursement—but may also reduce the number of completed preventive visits if not handled carefully.
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🚨 Compliance Still Matters: Audits on the Rise

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As RPM and RTM gain traction, so does government scrutiny:
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• HHS OIG published a 2024 report calling for greater oversight of RPM billing
• Multiple DOJ settlements have occurred where RPM vendors billed improperly—often billing under their own NPI without direct patient care
• CMS is clear: compliance isn’t optional

✅ What this means for you: Choose your technology and service partners wisely. Good-faith programs, backed by transparent data and proper coding, are key to avoiding risk.

✅ Key Takeaways for Providers in 2026
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• New RPM codes (99XX4 + 99XX5) expand billing opportunities for lighter-touch monitoring and brief interactions
• Virtual direct supervision becomes a permanent option for most remote care services
• G0511 is sunset — FQHCs and RHCs must transition to CPT-based billing
• APCM grows — new codes support behavioral health integration and potential bundling with prevention
• Compliance is critical — OIG and DOJ are actively auditing RPM billing

🛠️ Future-Proof Your Remote Care Program with CCN Health

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Whether you’re billing under 99454, 99XX4, 99457, 99XX5, or any other care management code, CCN Health makes it easy to manage everything in one platform:
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• Supports RPM, RTM, CCM, BHI, PCM and more
• Fully integrated with a growing number of EHRs → See the list
• Auto-syncs vitals from CCN or third-party devices
• Built-in dashboards show what’s billable, what’s not, and why
• Custom workflows and smart automations to match how your team works

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📊 One system. All your remote care programs. Fully compliant. Built for scale.