RPM Manual
The practical 2026 guide to device rules, day thresholds, management time, and audit defensibility for Remote Patient Monitoring.
Read the RPM Guide →The "Block Gapping" Trap: Why Pausing RPM Cycles Leads to Audits
The Bottom Line
- The Definition: "Block Gapping" is when a vendor "pauses" a patient's 30-day billing clock because they haven't reached 16 days of readings yet.
- The Risk: CPT 99454 is a time-based code (30 days). You cannot arbitrarily extend a 30-day period to 45 or 60 days just to capture enough readings.
- The Consequence: Auditors look at the "Date of Service" span. If your periods are irregular (e.g., Jan 1–30, then Feb 15–Mar 15), it flags the claim as manipulated.
- The Fix: Run strictly on calendar months or fixed 30-day rolling windows. If a patient misses the 16 days, you do not bill. You do not "gap" them.
Read the deeper breakdowns:
Visualizing the "Gap"
Many outsourced RPM vendors operate on a revenue-share model. This incentivizes them to ensure every patient is billable every time, even if it requires manipulating the rules. "Block Gapping" is a technique used to artificially increase billable units.
| Standard Compliance (FairPath) | "Block Gapping" (Vendor Risk) |
|---|---|
| Cycle 1: Jan 1 – Jan 30 (16 readings) Bill | Cycle 1: Jan 1 – Jan 30 (16 readings) Bill |
| Cycle 2: Jan 31 – Feb 28 (10 readings) No Bill | "The Gap": Vendor pauses clock for 2 weeks to wait for data. |
| Cycle 3: Mar 1 – Mar 30 (16 readings) Bill | Cycle 2: Feb 15 – Mar 17 (16 readings) Audit Flag |
In the "Block Gapping" example, the vendor has disconnected the billing cycle from the calendar. When an auditor requests your raw device logs, they will see that the readings used to justify "Cycle 2" were actually collected over a span of 45+ days, violating the CPT definition of a 30-day period.
"CPT code 99454 is for the supply of the device for scheduled recordings and/or programmed alert transmissions... each 30 days."
– AMA CPT Manual
Video Transcript
0:00 Are you paying a vendor to manage your RPM program? You might be at risk of something called "Block Gapping."
0:05 Here is how it works. A patient is supposed to be billed every 30 days. Let’s say in January, they get their 16 days of readings. Great, you bill it.
0:12 But in February, the patient goes on vacation. They only transmit data for 10 days. You cannot bill CPT 99454 for that month.
0:20 A compliant practice simply accepts that loss and starts a new cycle in March. But a vendor? They don't get paid unless you get paid. So they do this:
0:28 They "pause" the billing clock. They leave that February cycle open... waiting... and waiting. Then, in the middle of March, when the patient starts taking readings again, they grab those new readings and "stuff" them back into the February bucket.
0:40 They send you a claim saying, "Hey, we got 16 days!" But they didn't get them in 30 days. They got them over 50 days. That is called Gapping. It breaks the CPT definition, and when the OIG asks for your device logs, the timestamps won't match the claim dates.
0:55 Don't let a vendor’s revenue model become your audit liability.
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