The world of telehealth is in constant motion, and staying abreast of the latest regulatory shifts from the Centers for Medicare & Medicaid Services (CMS) is paramount for healthcare providers. As a recognized leader in remote patient monitoring (RPM) and comprehensive telehealth solutions, Health Recovery Solutions (HRS) is meticulously tracking CMS's proposed billing code updates for 2026. These changes, slated to take effect on January 1st, could significantly reshape your organization's patient care strategies and financial outlook.
Let's delve into what these proposed changes could mean for you – highlighting both the opportunities and potential challenges – and how partnering with HRS can empower you to maximize the former and seamlessly navigate the latter.
A Broader Lens: RPM within the Evolving Telehealth Framework
These proposed 2026 updates for RPM are not isolated changes; they reflect a broader legislative and regulatory evolution shaping the future of telehealth and virtual care. While various recent laws, such as the Consolidated Appropriations Acts, have extended many general Medicare telehealth flexibilities (like originating site waivers and audio-only options for some services) through September 30, 2025, it's crucial to understand RPM's unique position.
CMS continues to categorize RPM (and Remote Therapeutic Monitoring - RTM) as "care management services" rather than traditional telehealth. This distinction is vital because it means they are not typically subject to the same originating site or geographic restrictions that apply to other telehealth services. This inherent flexibility for RPM is a significant advantage that has largely remained consistent, even as other telehealth policies have seen temporary extensions or more stringent criteria. The current proposals for 2026 further solidify CMS's commitment to supporting RPM as a distinct and valuable component of chronic disease management and post-acute care, focusing on refining its billing mechanisms and expanding its applicability to diverse patient needs.
What's New with Remote Patient Monitoring (RPM) Billing Codes for 2026?
CMS continues to refine its approach to RPM, striving to encourage its widespread adoption while simultaneously ensuring appropriate and effective utilization. A crucial point to remember is CMS's clarification that RPM and Remote Therapeutic Monitoring (RTM) services are inherently non-face-to-face. This distinction is vital because it means they are not subject to the same geographic or originating site restrictions that apply to traditional Medicare telehealth services, offering significant flexibility for providers.
Here's a breakdown of some key proposed adjustments:
For Existing RPM CPT Codes (99453, 99454, 99091, 99457, 99458):
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CPT Code 99091 (Collection and Interpretation of Physiologic Data): For Calendar Year (CY) 2026, CMS is proposing to maintain the current work Relative Value Unit (RVU) of 1.10 for CPT code 99091. This is good news for providers, as it actively avoids a potential reduction in reimbursement for this foundational service, despite a recommendation from the Relative Value Scale Update Committee (RUC) for a lower value of 0.70 work RVUs.
Context Corner: What are RVUs and the RUC?
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RVUs (Relative Value Units) are a core component of how Medicare determines payment for physician services. They reflect the resources (physician work, practice expense, and malpractice insurance) typically required to provide a service. Higher RVUs generally mean higher reimbursement.
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The RUC (Relative Value Scale Update Committee) is an independent, physician-led committee of the American Medical Association (AMA) that makes recommendations to CMS on the value of new and existing CPT codes. While CMS isn't obligated to accept RUC recommendations, they often do.
However, a significant point to note is that CPT code 99091, along with other RPM codes (99457 and 99458, and the new proposed codes 99XX4 and 99XX5), did not meet the minimum survey requirements established by the RUC for the January 2025 meeting. As a result, CMS plans for it to be resurveyed after one year of utilization data is available for the 2026 CPT code structure, with all RPM codes expected to be reviewed at the January 2028 RUC meeting. This indicates that future adjustments are still very possible, emphasizing the need for ongoing vigilance.
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CPT Code 99457 (First 20 minutes of treatment management): CMS is proposing to maintain the current work RVU of 0.61, the current work time of 20 minutes, and the current direct practice expense (PE) inputs. Similar to 99091, this consistency is also due to the code not meeting minimum survey requirements.
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CPT Code 99458 (Each additional 20 minutes of treatment management): CMS is proposing to adopt the RUC-recommended work RVU of 0.61, but to maintain the current direct PE inputs. This too is attributed to the lack of sufficient survey data.
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16-Day Rule for 99453 (Initial setup and patient education) and 99454 (Subsequent monitoring): Consistent with 2025, to bill for CPT codes 99453 and 99454, the patient must use the RPM device for at least 16 days a month. This continued consistency provides a welcome element of stability for program planning and operational workflows.
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Relativity between RPM and RTM: CMS continues to emphasize maintaining relativity between RPM and RTM codes that describe equivalent amounts of treatment management time and effort, promoting a balanced approach to reimbursement across these similar virtual care modalities.
Introducing New Proposed RPM Codes (99XX4 and 99XX5):
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CMS is proposing two groundbreaking new CPT codes, 99XX4 and 99XX5, specifically designed by the CPT Editorial Panel to describe RPM services with less than 16 days of data transmission per 30-day period (for 99XX4) and less than 20 minutes of interactive communication per month (for 99XX5).
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The Good: These new codes offer significantly greater flexibility for billing RPM services that might not meet the current 16-day data transmission threshold for 99454, or the 20-minute interactive communication threshold for 99457/99458. This could open up new pathways for shorter-term monitoring, transitional care, or more flexible patient engagement models, allowing providers to cast a wider net for patient eligibility. Specifically, 99XX5 is proposed for the first 10 minutes of remote physiologic monitoring treatment management services, including one real-time interactive communication with the patient or caregiver per month. This provides a crucial billing option for shorter, focused interactions that might not have been billable under existing, more rigid codes.
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The Bad: The introduction of any new codes inevitably brings an initial learning curve for understanding their specific requirements, nuances, and how they integrate into existing clinical and billing workflows. For 99XX5, CMS is proposing a work RVU of 0.31, which is notably lower than the RUC's recommendation of 0.39. This indicates a lower reimbursement for these shorter engagements compared to more comprehensive RPM codes like 99457 (0.61 RVU), suggesting CMS intends to value these less intensive interactions accordingly.
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Concerns about "Digital Remote Physiologic Monitoring Device App" (99XX4 and 99454): CMS has raised concerns that the RUC's recommendations for the PE-only codes 99XX4 and 99454 include a "digital remote physiologic monitoring device app." This, they note, is a per-click vendor fee and not traditionally included as a form of direct practice expense. While CMS acknowledges the challenge of accounting for software and digital tools in reimbursement, they express concerns about verifying the pricing for these inputs. They believe using Hospital Outpatient Prospective Payment System (OPPS) cost data may more accurately reflect the value of these services.
Context Corner: What is the OPPS?
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The Hospital Outpatient Prospective Payment System (OPPS) is how Medicare pays hospitals and community mental health centers for outpatient services provided to Medicare beneficiaries. By referencing OPPS data, CMS aims for more consistent and transparent valuation across different healthcare settings.
This shift suggests a move towards a more data-driven and potentially conservative approach to valuing digital health components, which providers and vendors should closely monitor.
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How HRS Empowers You to Thrive Amidst Change
These proposed 2026 CMS changes represent both challenges and exciting opportunities for healthcare organizations. By partnering with Health Recovery Solutions (HRS), you gain a trusted expert team and a robust, clinically-validated platform to not only navigate these complexities but to truly excel in delivering advanced virtual care and achieving your financial and patient outcome goals.
Here's how HRS stands as your invaluable partner:
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Expert Reimbursement Support: HRS's in-house reimbursement specialists are dedicated to helping you decipher and successfully claim reimbursement from various sources, including CMS, commercial payers, and private pay options. We offer 1:1 reimbursement consultations, ongoing education on the latest updates and grant funding opportunities, and monthly reimbursement reporting through HRS Analytics to help you clearly demonstrate program ROI. This comprehensive support means you can confidently leverage new billing opportunities, like those offered by the proposed new RPM codes, while minimizing the "bad" impacts of ambiguity and evolving regulations.
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Clinically-Enabled, Patient-Centric Solutions: HRS provides the industry's leading remote care management platform, designed by clinicians, for clinicians. Our solutions are built to be both clinically enabled and profoundly patient-centric, ensuring patients and care teams are always seamlessly connected. This includes intuitive tools and features like:
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CareConnect™ for 24/7 clinical monitoring and triage, effectively augmenting your existing staff and extending your reach.
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WoundConnect™ for revolutionizing and simplifying complex wound care management.
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ClinicianConnect®, a robust patient management portal that integrates seamlessly with your EHR, streamlining workflows and reducing administrative burden.
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Expertly crafted operational workflows, clinical playbooks, and tailored training to help you build and scale a successful, sustainable RPM program from the ground up.
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Scalable Logistics and Implementation: Beyond just providing devices, HRS understands that the intricacies of RPM logistics are critical for success. Our dedicated team assists you with every step of program setup, efficient device supply chain management, and ensuring seamless patient onboarding and transitions. This expertise enables you to confidently monitor 100 patients or 1,000+, effectively offloading time-consuming and complicated processes so your team can focus where it matters most: direct patient care.
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Actionable Data and Insights: With HRS Analytics, you gain the power to make data-driven decisions on your RPM program's performance. Our comprehensive reports help you clearly demonstrate program ROI, pinpoint inefficiencies, and uncover valuable opportunities to strategically scale your virtual care initiatives. This is absolutely critical for adapting to evolving reimbursement models and definitively proving the immense value of your telehealth services to stakeholders.
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Proven Results: HRS boasts a strong, consistent track record of success, having been awarded the Frost & Sullivan Customer Value Leadership Award for RPM. Our unwavering commitment to a longitudinal model of care supports seamless transitions of care, significantly reduces avoidable readmissions, and minimizes unnecessary emergency department visits, delivering tangible benefits for both patients and providers.
The proposed 2026 CMS changes underscore the dynamic nature of telehealth, presenting both challenges and exciting opportunities for healthcare organizations. By partnering with Health Recovery Solutions, you gain a trusted expert team and a robust platform to confidently navigate these complexities, optimize your virtual care programs, enhance patient outcomes, and strengthen your financial future.
Ready to explore how HRS can help your organization prepare for 2026 and beyond? Contact us today to schedule a demo and speak with a Digital Health Advocate!