RPM Manual
The practical 2026 guide to device rules, day thresholds, management time, and audit defensibility for Remote Patient Monitoring.
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Operational Compliance Brief
The Pharmacy Firewall: Allocating Part B Clinical Time vs. Part D Dispensing
Pharmacists expanding into Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) must navigate the distinction between Medicare Part D (Dispensing) and Medicare Part B (Medical Services) to avoid "duplicate payment" risks.
Published: February 3, 2026
For Pharmacy Owners, Compliance Officers
Compliance Note: This guide addresses the "Program Integrity Risk" of billing Medicare Part B for work that is covered under the Part D dispensing fee. Adopting these internal controls creates a defensible audit trail. This resource is educational and does not constitute legal advice; confirm program design with qualified counsel and your Medicare billing practitioner.
The Core Conflict
The Trap
Part D dispensing fees cover dispensing-related pharmacy costs at the point of sale and the transfer of the drug. If you bill Part B (RPM) for time spent facilitating this transfer, you risk an overpayment audit.
The Solution
Establishing a "Clinical Firewall"—a distinct operational separation between dispensing duties and clinical management time.
The Outcome
A sustainable revenue stream where clinical services are documented with "Distinct Intent," improving defensibility in the event of a documentation review or audit.
Overview
To build a compliant revenue stream from remote care, pharmacy owners must understand the specific definition of the Dispensing Fee they already receive under Part D.
The regulation defines dispensing fees as pharmacy costs at the point of sale associated with transferring the Part D drug to the enrollee and includes examples like pharmacist time for coverage checks and quality assurance activities. When remote care interactions drift into dispensing logistics or refill facilitation, documentation can blur the boundary between Part D dispensing work and Part B care management work.
This creates an allocation risk: If a pharmacist bills CPT 99457 (RPM Management) for a call that is primarily about refilling a prescription, an auditor could determine the service was already paid for under Part D. This brief outlines how to structure your operations to prevent this overlap.
Key Takeaway
Billing Medicare Part B for work that is substantially "dispensing-associated" creates a risk of overpayment exposure. Pharmacies must establish a "Clinical Firewall" where every billable Part B minute has a documented Clinical Intent distinct from the logistic transfer of a drug.
I. The Regulatory Context
The Definition (42 CFR § 423.100)
Under federal regulations, the dispensing fee is intended to cover costs incurred at the point of sale. Specifically:
Dispensing fees are defined as costs incurred at the point of sale to transfer the drug to the enrollee, including pharmacy costs such as pharmacist time for coverage checks, quality assurance, and packaging. [1]
The Program Integrity Risk
Billing Medicare Part B for work that is "dispensing-associated" creates potential liability for duplicative billing.
Example Risk: A pharmacist bills CPT 99457 (20 minutes of RPM management), but the documentation shows the call was primarily about explaining a copay or scheduling a delivery. This increases audit risk because documentation may support a determination that the work was dispensing associated rather than Part B care management.
II. The MTM vs. RPM Distinction
Pharmacies often run Medication Therapy Management (MTM) programs (Part D) alongside RPM/CCM programs (Part B). While complementary, these programs have distinct funding streams. Medicare generally does not allow separate payment for the same work billed under two different mechanisms.
The "Muddy Middle": Medication Reconciliation
The Risk Scenario
A pharmacist reviews an RPM blood pressure log and notices an adherence gap. If the pharmacist simply facilitates a refill, that is a Part D activity.
The Compliant Path
If the pharmacist identifies a side effect, consults with the patient regarding the physiological data, and communicates a recommendation to the prescribing provider or billing practitioner under an authorized collaborative practice agreement where permitted, that is a billable Part B clinical activity.
III. The Solution: Internal Control Protocols
To mitigate audit risk, pharmacies should establish a "Clinical Firewall"—an operational separation between dispensing duties and clinical management.
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1. The "Distinct Intent" Standard
Every billable Part B minute should have a documented Clinical Intent.
Dispensing Workflow: "Calling to notify patient that refill is ready."
Clinical Workflow: "Calling to review trends in systolic blood pressure data and assess therapeutic response." -
2. Operational Control: Time Log Separation
It is a recommended best practice to maintain contemporaneous time logs. Avoid interleaving dispensing tasks (e.g., counting pills) inside the same timed clinical episode. Staff should ideally complete their dispensing queue before switching "hats" to perform dedicated care management blocks.
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3. Consent and Enrollment Artifacts
Ensure you capture and maintain patient consent and enrollment documentation specific to RPM and CCM programs. CMS remote monitoring guidance emphasizes consent requirements, and making this explicit in your records increases defensibility.
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4. One Billing Practitioner Rule
Only one practitioner should bill RPM per patient in a 30-day period. Align workflows with the billing practitioner and ensure your documentation reflects the responsible billing practitioner’s review and direction to avoid overlapping claims.
IV. "Incident To" and General Supervision
Under 42 CFR § 410.26, services can be billed "incident to" a physician's professional service if they are furnished by auxiliary personnel under the physician's supervision.
The Supervision Rule
Medicare allows designated care management services (including RPM and CCM) to be furnished under General Supervision [2][3]. This means the service is furnished under the practitioner’s overall direction and control, but the physician's physical presence is not required during the service.
What this means for Pharmacy
The supervising physician creates the care plan, but the pharmacy staff (acting as auxiliary personnel, subject to state scope of practice) can perform the monitoring remotely. This creates the legal framework for the "Integrated Pharmacist" model.
V. How FairPath Supports Clinical Firewall Operations
FairPath is designed to support the documentation discipline required for compliant operations. Note: Software supports documentation and workflow discipline; it does not determine billing eligibility.
Role-Based Workflows
Distinguishes dispensing tasks from care management tasks within the platform to support clear separation of duties.
Clinical Context Timers
Timer entries require selection of a clinical reason category and are stored with user attribution, timestamps, and linked patient data artifacts.
Structured Note Templates
Prompts documentation of clinical intent and action, including escalation to the billing practitioner.
Audit Packet Exports
Exports care logs including time entries, triggering data context (e.g., BP readings), and supervising billing practitioner attribution.
Enrollment Tracking
Dedicated fields for consent capture and enrollment tracking for RPM and CCM programs.
FAQ Section
1
Can I bill RPM management time while filling a prescription?
You should not count time that is contemporaneous with dispensing workflow toward RPM/CCM time. Part D dispensing fees are intended to cover point-of-sale dispensing-related pharmacy costs associated with transferring the drug. Mixing dispensing work into timed Part B care management creates an overpayment documentation risk. Use separate clinical workflow blocks and document clinical intent.
2
Does MTM count toward RPM time?
Do not double count the same staff minutes across Part D MTM and Part B RPM. RPM treatment management codes require distinct documented time and work effort. You should maintain clear time allocation and clinical documentation showing what work supported the Part B service versus Part D sponsor MTM activities. MTM is a Part D sponsor program and is not billed to Part B via CPT in the same manner.
3
What is 'General Supervision' for pharmacy staff?
Under 42 CFR 410.26, designated care management services can be furnished under general supervision when provided incident to a billing practitioner. General supervision means the service is furnished under the practitioner’s overall direction and control, and the practitioner’s physical presence is not required. Auxiliary personnel may perform the work, subject to applicable state law and scope of practice.
4
How do we document 'Clinical Intent'?
Your documentation should explicitly state the purpose of the interaction. Instead of "Called patient about refill," the note should read "Reviewed systolic blood pressure trends and assessed therapeutic response."
References
- 42 CFR § 423.100 - Definitions (Dispensing fees). Electronic Code of Federal Regulations.
- 42 CFR § 410.26 - Services and supplies incident to a physician's professional services.
- CMS MLN909188 Chronic Care Management Services booklet (June 2025).
- CMS MLN901705 Telehealth and Remote Monitoring (Dec 2025).
FairPath is designed to handle this complexity for you.
While most platforms simply record what happened, FairPath actively runs the program. It continuously monitors every patient, staff action, and billing rule across CCM, RPM, RTM, and APCM, intervening immediately when a requirement is missed.
This allows you to scale your own program without losing quality, breaking trust with physicians, or losing control of your revenue. We provide the precision of an automated medical director without the chaos.
