The CY 2027 MPFS Proposed Rule is here: What’s at Stake for RPM, RTM, and Care Management?
Key Takeaways:
CMS proposes to allow payment for RPM and RTM only when the clinical staff furnishing the service are direct employees of the billing practitioner or the practice. Contracting out to third-party companies would no longer support billing as of January 1, 2027. For companies built on contracted clinical staff, this is a change to the operating model.
Current CMS regs allow for contracted auxiliary staff. CMS moved RPM to general supervision in CY 2020 after practices reported that direct supervision made RPM programs impractical, and stated in CY 2021 that auxiliary personnel furnishing RPM "may include contracted employees." The proposal would reverse that position without addressing the conflict.
Both RPM and RTM would be limited to established patients and would require an initiating visit.
CMS is also considering collapsing 17 codes into four G-codes, which would likely result in significant payment reductions.
Every restriction CMS proposes for RPM appears as an open question about care management in the same rule's primary care RFI. Those RFI questions are the CY 2028 proposals in draft form.
Nixon Law Group has been at the forefront of remote monitoring policy since CMS first established reimbursement for Remote Physiologic Monitoring (“RPM”) in 2019. We've seen our clients' comments produce the Remote Therapeutic Monitoring (“RTM”) code set, we've defended companies through the first wave of MAC audits, and we've helped dozens of digital health companies build and scale compliant programs.
The CY 2027 Physician Fee Schedule proposed rule is the most consequential thing to happen to remote monitoring since the service was created. CMS is proposing a sweeping set of structural, clinical, and financial refinements to the RPM and RTM codes, alongside a comprehensive Request for Information (“RFI”) on the future of care management.
As proposed, it will take the industry back in time, from bundling, to unbundling, and bundling once again. If finalized, these proposals will take effect January 1, 2027.
Rather than viewing these proposals with (understandable) alarm, digital health companies and medical practices should seize this opportunity to provide CMS with real-world data, clinical workflows, and alternative pathways that protect both program integrity and patient access.
Below, we’ve broken down the major shifts you need to know about, along with strategic focus areas for public comments to CMS before the September 14, 2026, deadline.
What Has CMS Proposed for RPM and RTM in the CY 2027 Fee Schedule?
The Direct Employment Mandate: No More Outsourced Clinical Staff
Medical practices have successfully scaled their remote monitoring programs by partnering with third-party digital health vendors. Under the traditional “general supervision” framework for Designated Health Services, a vendor’s clinical staff could monitor incoming data and manage patient outreach.
Citing Office of Inspector General (“OIG”) concerns over third-party companies “cold calling” beneficiaries and the fragmentation of patient care, CMS is proposing a strict direct employment mandate as follows:
Direct Payroll Only: To count clinical staff time toward billing RPM or RTM, the staff member must be a direct employee of the billing practitioner or the practitioner’s practice.
The End of Third-Party Staffing: Practices will no longer be allowed to outsource monitoring labor to third-party companies that provide clinical staff.
Supervision vs. Payroll: While clinical staff do not need to be physically located at a practice and can still operate under general supervision, they must meet all “incident to” requirements and be on the practice’s direct payroll.
Not Applicable to Technology: CMS is not proposing to prohibit practices from purchasing technology, devices, software, analytics, or administrative services from vendors. The proposed restriction is directed at vendors that provide clinical staffing services.
OF NOTE: Chronic Care Management (“CCM”) services are explicitly not included in the proposed direct employment mandate. This means that, for now, the outsourced clinical staffing model remains intact for CCM (and presumably, other care management services), but not for RPM and RTM.
Patient Eligibility and Initiating Visit Requirements
CMS is proposing to raise the bar on how and when a patient can be enrolled in RPM and RTM services as follows:
Established Patients Only for RTM: RTM would be brought into alignment with RPM and explicitly require that practitioners have an established relationship with a patient before providing RTM services. (Currently, an established patient relationship is only required for RPM).
Mandatory Initiating Visit:All RPM and RTM services would be required to be initiated during a separately reportable face-to-face visit (in-person or via telehealth). RPM or RTM must be explicitly discussed with the patient during that visit; if it is not, then the services cannot be initiated or billed. Note that currently, an initiating visit is only required for new patients or patients who have not been seen within a year prior to starting RPM.
Significant Reimbursement Reductions
CMS is also proposing significant valuation reductions across all remote monitoring codes, stating that a lack of robust device cost and invoice data has led to overvaluations. For example:
Setup and Education (99453, 98975): CMS proposes to crosswalk Practice Expense inputs to the lower-valued CPT 99473 (self-measured blood pressure training) to better reflect typical office resource costs.
Device Supply Codes (99445, 99454, 98976, 98977, 98978, 98984, 98985, 98986): CMS proposes to crosswalk device supply inputs to lower baseline codes (CPT 99474 for RPM (self-measured blood pressure device); CPT 93720 for RTM (external ECG loop recording)), suspecting that market price of these devices has dropped over time and there is a lack of documentation to prove otherwise.
Stripping PE from Treatment Management (99470, 99457, 99458, 98979, 98980, 98981): CMS is proposing to completely eliminate Practice Expense (PE) inputs from the treatment management codes, leaving only the raw “work RVUs.” CMS asserts that the typical clinical workflow for these monthly management blocks does not involve extra clinical staff time beyond the physician/qualified healthcare practitioner work.
Bundling Remote Monitoring Codes (The Proposed G-Codes)
In an effort to alleviate administrative burdens and ensure patients receive all components of remote monitoring, CMS is seeking comment on compressing the 17 existing remote monitoring codes down to four new HCPCS G-codes.
GPRM1: RPM initial set-up and patient education.
GPRM2: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), per calendar month, including:
Device(s) supply with daily recording(s) or programmed alert(s) transmission.
2 or more days of data transmission.
Treatment management services, requiring at least one real-time interactive communication with the patient/caregiver; time totaling at least 20 minutes.
GRTM1: RTM initial set-up and patient education
GPTM2: Remote monitoring of therapeutic parameter(S) (eg, therapy adherence, therapy response, digital therapeutic intervention), per calendar month, including:
Device(s) supply for data access or data transmissions.
2 or more days of data transmission.
Treatment management services, requiring at least one real-time interactive communication with the patient or caregivers; time totaling at least 20 minutes.
To bill the monthly monitoring codes (GRPM2 and GRTM2), all elements in the descriptor must be met every single calendar month. Currently, practices are not required to bill for both device supply and treatment management each month.
Beyond Remote Monitoring: The Care Management RFI
CMS is also taking a step back to evaluate the entire landscape of care management. Currently, CMS pays separately for care management services that were historically bundled into Evaluation and Management (“E/M”) visits through the CCM, Principal Care Management (“PCM”), Transitional Care Management (“TCM”), and Advanced Primary Care Management (“APCM”) codes, in addition to RPM and CCM.
CMS notes in the Proposed Rule that uptake of care management services has been surprisingly limited, with providers citing cost-sharing and excessive documentation requirements as major barriers. In response, CMS has opened a broad Request For Information aimed at a potential reconfiguration of the “care management code family.”
This RFI presents a real opportunity for digital health platforms and practices to shape how Medicare pays for tech-enabled care management. Below are some of the key questions CMS is asking. Of interesting note, the answers to these questions seems to be presumed in the RPM and RTM proposals:
What is the appropriate “trigger” or initiating visit for care management services? Should CMS change supervision requirements to prevent fraudulent billing?
What proportion of care management services must be delivered by the supervising practitioner versus auxiliary personnel?
To what extent are current care management codes duplicative? Are there efficiencies to be gained in simplifying the current code family into an efficient code set?
As care management becomes increasingly technology-enabled, how should CMS change the code family and relative valuations? Should CMS create “technology-enabled care management” codes or a “two-track” approach?
Next Steps for Digital Health Stakeholders
The proposed direct employment mandate, mandatory initiating visit, and rate cuts will likely fundamentally alter your operations. Over the years, we’ve seen the direct results of comments submitted on behalf of our clients. Detailed clinical and financial data is helpful to provide. Comments are due to CMS by September 14, 2026.
Need help analyzing how the Proposed Rule may affect your business, or want assistance drafting and submitting comments to CMS? Contact Nixon Law Group today.
Frequently Asked Questions (FAQs)
Would CMS really prohibit the use of third-party outsourced staff for RPM and RTM services?
That is the proposal. CMS would allow payment only when the clinical staff furnishing RPM or RTM are direct employees of the billing practitioner or the practice. Beginning January 1, 2027, the codes could not be billed where the service is performed by contracted third-party staff. Staff need not be physically located in the practice, and general supervision plus the other "incident to" requirements would still apply, but the employment relationship would become a condition of payment.
Didn't CMS specifically allow contracted clinical staff for RPM?
Yes. In the CY 2020 PFS final rule, CMS designated CPT codes 99457 and 99458 as designated care management services, permitting general supervision rather than direct supervision. CMS made this change in response to feedback from practices indicating that direct supervision made RPM programs impractical for them to administer. In the CY 2021 PFS final rule, CMS finalized that auxiliary personnel could furnish 99453 and 99454, and its fact sheet stated that auxiliary personnel "may include contracted employees." The CY 2027 proposal would reverse that position without addressing the earlier rules.
Does the RPM employment requirement apply to Chronic Care Management?
No. The proposal is limited to RPM and RTM. But CMS asks in the same rule's primary care RFI what proportion of care management services must be delivered by the supervising provider "versus auxiliary personnel," and whether care management supervision requirements should change. Of significance -- OIG began a multi-year audit of CCM services in March 2026. If the RPM proposals are finalized, we consider CCM restrictions just a question of timing.
What is the initiating visit requirement for RPM and RTM?
CMS proposes that RPM and RTM be initiated by the billing practitioner during a separately reportable, face-to-face visit, in person or via telehealth. Codes that don't involve a face-to-face visit by the billing practitioner, or that aren't separately payable, can't serve as the initiating visit. If remote monitoring isn't discussed at the visit, it doesn't qualify. The visit is separately billable.
What are GRPM1, GRPM2, GRTM1, and GRTM2?
These represent four G-codes that CMS is considering in place of the current 17 remote monitoring codes. GRPM1 and GRTM1 would cover initial set-up and patient education. GRPM2 and GRTM2 would be monthly bundles requiring device supply, at least two days of data transmission, and at least 20 minutes of treatment management including a real-time interactive communication, all in the same calendar month. CMS has not proposed payment rates for any of them.
When is the comment deadline for the 2027 remote monitoring proposals?
September 14, 2026. Comments may be submitted at regulations.gov referencing file code CMS-1848-P. We’re happy to help!