23 must-have items before an RPM or APCM review, plus a plain-English summary of 7 new repayment triggers.
Instruction: Use this as a pre-submission checklist at least once a quarter.
A. Program Basics
B. Patient Enrollment & Consent
C. RPM Evidence & Billing
D. APCM Requirements
E. Compliance & Supervision
F. Audit Trail & Vendor Risk
7 Repayment Triggers
Plain-English summary of CMS & payer rule changes that lead to refunds.
Rule 1: The Prior Relationship
Prior relationship and consent are no longer optional. CMS expects clear proof of a legitimate relationship before RPM starts. Missing prior visits or vague consent are common grounds for recoupment.
Rule 2: The Three-Part Service
RPM is not just device rental. Auditors look for Setup, Device Use, AND Clinical Management. If claims show device codes without evidence of management/onboarding, payers treat those as overpayments.
Rule 3: Strict Day Counts
Device codes (99454) are tied to explicit day ranges (16 days). If logs show fewer days than required, payers demand refunds even if you "almost" met the threshold.
Rule 4: No Double Dipping
Only one practitioner can bill RPM per patient per 30 days. You cannot stack RPM and RTM for the same patient/period. Duplicate billing is low-hanging fruit for auditors.
Rule 5: APCM Stacking Limits
Billing both APCM BH add-ons and standalone CoCM/BHI codes for the same patient/month is treated as double payment and routinely reversed.
Rule 6: Supervision Details
Auditors expect you to show WHO supervised non-physician work and HOW (in-person vs. real-time video). If documentation can't tie work to a supervisor, services are disallowed.
Rule 7: Vendor Liability is YOUR Liability
When vendors generate "minutes" your chart doesn't support, payers ask you for the refund, regardless of what your vendor contract says.
Provided by FairPath — The Compliance-as-Code Platform.