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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDHA RPM Reimbursement Coverage Update | OpenPayer
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    ModifiedDHAPolicy 4.0

    Remote Physiologic Monitoring (RPM) Reimbursement Policy

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    TRICARE requirements for coverage, coding, equipment, exclusions, and cost-sharing for medically necessary remote physiologic monitoring services.

    Policy Summary
    PayerDHA
    PolicyRemote Physiologic Monitoring (RPM)
    Policy CodePolicy 4.0
    Change TypeModified
    Effective DateMar 13, 2020
    Next Review DateN/A
    Key ActionUse only FDA-approved devices that meet TRICARE's durable equipment or durable medical equipment definition for medically necessary RPM.
    SourceLink
    POLICY UPDATE CHANGES

    The RPM exclusion section was revised in Revision 119 to exclude devices and equipment that do not meet TRICARE's definitions of durable equipment or durable medical equipment.

    Mobile Medical Applications not listed in the referenced TRICARE durable equipment policy were added to the RPM exclusions in Revision 119.

    20 minMinimum clinical staff time
    12 moChronic condition duration
    16 daysAcute-condition data
    FDA-approvedDevice status

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    24 hrVideo/image follow-up

    Remote Physiologic Monitoring Coverage

    RPM coverage criteria

    Medically necessary RPM services are covered when all of the following requirements are met:

    ALL of the following

    • ALL of the following

      • The beneficiary requires at least 20 minutes of clinical staff time directed by a TRICARE-authorized provider during each 30-day period
      • A comprehensive care plan is established, implemented, revised, or monitored

      • ONE of the following condition requirements is met

        • The beneficiary has a chronic condition expected to last at least 12 months or until the beneficiary's death
        • The beneficiary has an acute condition that places the beneficiary at significant risk of death, acute exacerbation or decompensation, or functional decline

      • ALL of the following

        • The device or equipment is approved by the U.S. Food and Drug Administration (FDA)
        • The device or equipment meets TRICARE's definition of Durable Equipment (DE) and/or Durable Medical Equipment (DME)

    RPM equipment and application exclusions

    RPM-related equipment and applications are not covered or cost-shared when any of the following exclusions applies:

    ANY of the following

    • The device or equipment does not meet TRICARE's definition of Durable Equipment (DE) and/or Durable Medical Equipment (DME)
    • The equipment is a personal computer, smartphone, tablet, smart watch, non-medical tracker, or weight scale
    • The application is a Mobile Medical Application (MMA) not listed in Chapter 8, Section 2.1, paragraph 3.12.5

    Billing Codes and Requirements

    Covered CPT RPM procedure codesCPTCovered
    99091Collection and interpretation of physiologic data, minimum 30 minutes every 30 days
    99453RPM setup and patient or caregiver education
    99454Device supplies with daily recordings or alert transmissions, each 30 days
    99457RPM treatment management with interactive communication for the first 20 minutes per calendar month
    99458RPM procedure code listed by the policy without a separate description
    Covered HCPCS remote assessment codeHCPCSCovered
    G2250Remote assessment of submitted recorded video or images, including interpretation and follow-up within 24 hours
    Excluded devices, equipment, and applicationsmixedNot Covered
    Personal computersNot eligible for cost-sharing when they do not meet TRICARE's DE/DME definitions
    SmartphonesNot eligible for cost-sharing when they do not meet TRICARE's DE/DME definitions
    TabletsNot eligible for cost-sharing when they do not meet TRICARE's DE/DME definitions
    Smart watchesNot eligible for cost-sharing when they do not meet TRICARE's DE/DME definitions
    Non-medical trackersNot eligible for cost-sharing when they do not meet TRICARE's DE/DME definitions
    Weight scalesThe scale itself is not eligible for cost-sharing because it does not meet TRICARE's DE/DME definition
    Unlisted Mobile Medical ApplicationsMMAs not listed in Chapter 8, Section 2.1, paragraph 3.12.5 are excluded
    Minimum Clinical Staff Time
    Minimum clinical staff timeAt least 20 minutes
    Measurement periodPer 30-day period
    Provider directionTime must be directed by a TRICARE-authorized provider
    Physiologic Data Collection and Interpretation
    Required timeAt least 30 minutes
    FrequencyEvery 30 days
    Applicable code

    Provider Billing and Compliance Actions

    Denial Risk

    Meet medical-necessity and care-plan criteria

    Bill medically necessary RPM only when the beneficiary receives at least 20 minutes of clinical staff time directed by a TRICARE-authorized provider per 30-day period and has a comprehensive care plan established, implemented, revised, or monitored. The beneficiary must also have either a chronic condition expected to last at least 12 months or until death, or an acute condition placing the beneficiary at significant risk of death, acute exacerbation or decompensation, or functional decline.

    Billing Rule

    Apply Medicare-aligned RPM coding

    Use the codes and definitions established by Medicare and the CPT/HCPCS manuals for RPM billing and coding, including subsequent Medicare guidance or regulation.

    Key Terms

    Remote Physiologic Monitoring (RPM)
    DefinitionRemote monitoring services of physiologic parameters
    Included parameterWeight
    Included parameterBlood pressure
    Included parameterPulse oximetry
    Included parameterRespiratory flow rate
    Durable Equipment and Durable Medical Equipment
    DE/DME meaningDurable Equipment and/or Durable Medical Equipment as defined by TRICARE
    Policy Summary
    PayerDHA
    PolicyRemote Physiologic Monitoring (RPM)
    Policy CodePolicy 4.0
    Change TypeModified
    Effective DateMar 13, 2020
    Next Review DateN/A
    Key ActionUse only FDA-approved devices that meet TRICARE's durable equipment or durable medical equipment definition for medically necessary RPM.
    SourceLink
    On This Page
    Remote Physiologic Monitoring CoverageBilling Codes and RequirementsProvider Billing and Compliance ActionsKey Terms
    CPT 99091
    ActivityCollection and interpretation of physiologic data digitally stored or transmitted by the patient or caregiver
    Chronic Condition Duration
    Expected durationAt least 12 months
    Alternative endpointUntil the beneficiary's death, if earlier
    Qualifying conditionChronic condition
    Acute-Condition Data Requirement
    Standard requirementAt least 16 days of data
    COVID-19 public health emergencyAt least 2 days of data
    Applicable conditionAcute-condition RPM billing
    Video/Image Follow-Up
    Follow-up timeframeWithin 24 hours
    Applicable codeHCPCS G2250
    Required servicesInterpretation and follow-up with the beneficiary
    Submission typeRecorded video and/or images submitted through store-and-forward technology
  1. 99091: Collection and interpretation of physiologic data, requiring at least 30 minutes every 30 days
  2. 99453: RPM equipment setup and patient or caregiver education
  3. 99454: RPM device supplies with daily recordings or alert transmissions, each 30 days
  4. 99457: RPM treatment management with interactive communication for the first 20 minutes per calendar month
  5. 99458: RPM procedure code listed by the policy
  6. G2250: Remote assessment of recorded video or images, including interpretation and follow-up within 24 hours
    7. Denial Risk

    Use eligible RPM equipment

    Use only U.S. Food and Drug Administration-approved devices and equipment in conjunction with medically necessary RPM. Devices and equipment must also meet TRICARE's definition of Durable Equipment or Durable Medical Equipment; equipment that does not meet those definitions is not eligible for cost-sharing.

    • Do not cost-share personal computers, smartphones, tablets, smart watches, non-medical trackers, or weight scales that do not meet TRICARE's DE/DME definitions.
    • Mobile Medical Applications not listed in Chapter 8, Section 2.1, paragraph 3.12.5 are excluded.
    Documentation Required

    Document the required data days

    For acute-condition RPM, include at least 16 days of data. During the COVID-19 public health emergency, at least two days of data may be used, consistent with applicable Medicare guidance.

    Billing Rule

    Apply RPM cost-sharing

    Apply the appropriate ancillary-service cost-shares and copayments to RPM services. RPM is considered an ancillary service under the TRICARE Reimbursement Manual.

    Eligibility requirementDevices and equipment must meet TRICARE's DE/DME definitions to qualify for RPM cost-sharing
    Excluded examplesPersonal computers, smartphones, tablets, smart watches, non-medical trackers, and weight scales
    Weight-monitoring clarificationDHA may cover RPM of weight, but the weight scale itself is not eligible for cost-sharing when it does not meet the DE/DME definition
    Mobile Medical Applications (MMAs)
    DefinitionMobile Medical Applications (MMAs) used in connection with RPM
    Covered-reference requirementAn MMA must be listed in Chapter 8, Section 2.1, paragraph 3.12.5
    ExclusionMMAs not listed in Chapter 8, Section 2.1, paragraph 3.12.5 are excluded from RPM coverage