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Billing RPM Under Capitation Agreements
How to think about Remote Patient Monitoring when you’re paid under Medicare Advantage, risk models, and other capitated contracts.
Remote Patient Monitoring (RPM) codes 99453, 99454, 99457, and 99458 are designed to be paid separately under Medicare’s fee-for-service schedule.
However, under capitated arrangements or managed-care contracts (including many Medicare Advantage plans), those same services are often treated as part of the global payment you already receive.
The CO-24 Denial
This page explains why you see CO-24 denials (“charges covered under a capitation agreement or managed care plan”) and what practical options you have when RPM isn’t separately reimbursable.
Coverage Models
Traditional Medicare vs. Medicare Advantage
Traditional Medicare (FFS)
- RPM services are separately billable under Part B.
- Claims go directly to the Physician Fee Schedule, one line item per service.
- No capitation. If requirements are met, it is paid.
Medicare Advantage (Part C)
- Plans pay providers according to private contracts, not just the fee schedule.
- Risk-bearing entities often pay on a capitated basis (PMPM) for "all covered services."
- Claims often trigger denial code CO-24: "charges covered under capitation agreement".
Important Exceptions: Carve-Outs & RHCs
Not all managed-care contracts are identical. Some plans carve out specific services from capitation. Historically, RPM is rarely carved out by default, but you should always check your contract.
Note on RHCs/FQHCs: As of 2024, CMS allows RHCs/FQHCs to bill RPM/RTM via G0511 (General Care Management), effectively carving it out of their all-inclusive rate.
Optimization
Best Practices for RPM in Capitated Plans
Avoid wasted effort and unnecessary denials by following these operational rules.
Verify Attribution Up Front
Confirm if you are the capitated primary entity. If you bill Medicare FFS for an MA member, expect a denial directing you to the plan.
Read Your Contracts
Check your provider manual for "carve-outs." If the contract is silent, assume RPM is bundled into the PMPM payment.
Suppress Known Denials
If a plan always denies 99454 as CO-24, stop submitting the claim. Continue to document internally for quality/risk, but save the administrative labor.
Watch Place of Service
RPM is a care-management service, not telehealth. Do not use telehealth modifiers unless the plan specifically demands them.
Get Policy in Writing
Ask provider relations directly: "Are RPM codes 99453–99458 payable outside of capitation?" A written policy excerpt is worth more than hours of phone appeals.
Handling CO-24 Denials
A CO-24 denial isn't usually a coding error; it's a contract signal. It means "We already paid you for this via capitation."
Use appeals only to correct routing errors. Use contract negotiations for true capitation issues.
Did you bill the right payer?
If you sent an MA patient's claim to Original Medicare, CO-24 is their way of saying "Not our patient." Resubmit to the plan.
Check Attribution
If you are a specialist and NOT the capitated primary provider, you may have grounds to appeal. The capitation might belong to the PCP, not you.
Use Denials as Intelligence
If denials are contractually correct, don't waste staff time on appeals. Pivot to alternative codes or PMPM renegotiation.
Alternatives When RPM Isn’t Paid
If RPM is bundled, look to other care management codes that might still be open.
Chronic Care Management (CCM)
Codes like 99490 are often separately payable even in capitated contracts. Medicare allows concurrent billing of RPM and CCM if minutes are distinct.
Transitional Care (TCM)
For post-discharge patients, 99495/99496 yields higher reimbursement and is less likely to be bundled than RPM.
Principal Care Management (PCM)
Focused on a single complex condition (e.g., Heart Failure). Use 99424/99425 for intensive management of one issue.
Value-Based Leverage
Use your RPM data (BP control, reduced admissions) to negotiate higher capitation rates or shared savings bonuses. The ROI may be in the contract, not the claim.
