AMA: On 16-Day Requirement for CPT Code 99454

AMA: On 16-Day Requirement for CPT Code 99454

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    The American Medical Association (AMA) has announced significant changes to remote patient monitoring (RPM) billing requirements, effective January 2026. The CPT Editorial Panel has eliminated the 16-day data transmission threshold for providers to bill RPM codes1.

    Previously, patients needed to use a device and transmit data for at least 16 days in a 30-day period for providers to qualify for billing. This requirement applied to CPT codes 99453, 99454, 99457, and 994581.

    The decision came after the panel’s meeting in Washington, D.C., from September 25-28, 2024, where they discussed medical billing code change proposals. The 16-day reporting requirement for the RPM device supply code, which had been a contentious issue in the industry, was removed1.

    Many providers argued that the 16-day threshold was too high and often unattainable, resulting in non-payment for services rendered. They contended that fewer days of data were sufficient for effective treatment based on remote monitoring1.

    It’s important to note that the Centers for Medicare & Medicaid Services (CMS) had already clarified in the CY2024 Medicare Physician Fee Schedule that the 16-day data collection requirement did not apply to treatment management codes 99457, 99458, 98980, and 989811.

    The AMA’s Relative Value Scale Update Committee (RUC) will reconsider pricing for these codes in January 2025. Experts anticipate that reimbursement for less than 16 days of data may be lower than the existing code1.

    These changes aim to make RPM services more accessible and financially viable for providers, potentially leading to increased adoption and improved patient care.

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