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Patient Eligibility and CMS Guidelines

Patient Eligibility and CMS Reimbursement Guidelines for RPM

Remote Patient Monitoring Services in USA is a mode of healthcare that allows non-face-to-face interaction between the patient and Care Provider by virtue of connector devices. It is based on the idea of preventative healthcare which emanated from the public health emergency in times of Pandemic. Since its inception, it has brought about a huge transformation in HealthCare, breaking away from the traditional ways of providing healthcare. It promises large perks to the patients and practices with effective application. With more and more growth and expansion of this system, physicians must be clear about patient eligibility and effective reimbursement.

Patient Eligibility for Remote Patient Monitoring

At the point of its inception, only the patients with chronic conditions were able to get facilitated but in the hard times it was found beneficial to ensure preventative healthcare for more healthcare services. Since then, it is getting more inclusive with rapidly broadening scope. The patients eligible for it are stated underneath:

Acute and Chronic Patients

Both Acute and Chronic Conditions are allowed to be enrolled for this program. At first it was only confined to the Chronic Patients but later on, CMS and the federal government has expanded the coverage of this program to extract maximum benefit.

Patients from Rural Areas and Nursing Homes

While ensuring the access to quality healthcare in the times of pandemic it was viable to include Patients from Rural Areas and nursing homes in the program as they were restricted to travel due movement restrictions.

Residents of States with RPM Legislation

Fifteen states in US including Alaska, Hawaii and Rhode-Island, have ratified legislation which binds the insurance companies to include remote patient monitoring in their services list therefore every resident from these states is entitled to these services.

Patients Under Medicare and Private Insurance Providers

In the rest of the states there is an intense urge and demand for legislation to include Remote patient monitoring services in the healthcare. However, it is pertinent that no state bares healthcare provider to enroll patients in RPM. Private insurance providers and the government funded Medicare pays for these services. Every person in US is entitled to these services.

Want to Check Patient Eligibility?

Reimbursement Guidelines Provided by Centre for Medicare and Medicaid Services

Reimbursement for Remote Patient Monitoring Services is generally covered by Medicare and Medicaid in some states while a large number of private insurance providers also provide coverage for it. It is a simple procedure regulated through Current Procedural Terminology (CPT) codes. These codes are considered for billing operations by the Providers.

The Centre for Medicare and Medicaid has prescribed valuable guidelines for the billing operations regarding reimbursement protocols.


Patients under Medicare Part B have to pay 20% of the total  HealthCare Cost. Medicare provides 80% of the total expenses.

(Any patient age 65 years or above, US resident, or a foreigner with permanent resident permit and living in US for 5 years is eligible for Part B Medicare)

Documented or Verbal Consent

Medicare demands written or verbal consent of the patient in this regard but private payers require it in black and white and it is documented along the medical records.

Recommendation of the Provider

A Provider is required to judge the Eligibility of a Patient for Remote Monitoring and a prescription in this regard is mandatory to be added with other medical records of the patient.

Minimum Span Required

A patient who has been monitored for 16 days is eligible to be covered by Medicare

Type of Monitoring Devices

All Monitoring Devices must be approved by the FDA (Food and Drug Administration) and capable of automatically uploading data to the system of physicians where it is considered for care plans.

Bottom Line

Owing to the potential benefits associated with it, Remote Patient Monitoring is rapidly progressing with more and more expansion in its scope. Now, it requires a more careful approach to carrying out its reimbursement as well as enrollment procedures. CMS has provided the pertinent guidelines for the smooth functioning of these services which are admissible for all concerning parties. Thus, Remote Patient Monitoring is developing and it has the potential to transform the world of healthcare.


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