How CMS 2026 RPM Policy Changes Will Change Healthcare Provider Pricing Models

IMPORTANT: The information below reflects PROPOSED changes from CMS, not finalized policy. These changes are subject to public comment and modification before final implementation.

Current Status

On July 14, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2026.

Comment Period: The 60-day comment period for the CY 2026 PFS proposed rule (CMS-1832 P) ends on September 12, 2025

Key Proposed Policy Changes

 Proposed Elimination of the 16-Day Data Requirement

Current Policy: Reimbursement under CPT code 99454 requires patients to transmit data for at least 16 days in a 30-day period.

Proposed Change: Currently, CPT 99454—which covers the supply of RPM devices and the collection of daily data for each 30-day period— requires at least 16 days of transmitted data in order to be billed. This threshold has been a barrier to reimbursement for providers managing patients requiring less frequent monitoring. CMS proposes to create a new code allowing billing for as few as 2 days of data transmission.

How CMS 2026 RPM Policy Changes Will Change Healthcare Provider Pricing Models


 Proposed Two-Tier Billing Structure

CMS is proposing a new billing framework:

  • New Code (2-15 days): CMS is proposing that the new 2-15 day code be reimbursed at the exact same rate as the 16-30 day code

  • Revised Code (16-30 days): The existing code would officially cover 16 to 30 days in a 30-day period

Significant Note: CMS is proposing the same reimbursement rate for the new codes covering 2–15 days of data as the existing codes that cover 16 days of data. This means payment would be the same regardless of whether data is transmitted for two days or for 16+ days within any 30-day period

 Proposed Shorter Clinical Interaction Codes

Current Policy: Billing codes (99457 and 99458) require at least 20 minutes of clinical interaction.

Proposed Change: These codes will allow providers to bill for interactions lasting less than 20 minutes, specifically covering 10-19 minute clinical sessions.

Potential Impact by Stakeholder (If Finalized)

 Health Systems

  • Expanded Patient Eligibility: More patients could qualify for RPM billing

  • Revenue Optimization: Ability to bill for brief patient interactions

  • Operational Efficiency: Better alignment with actual nursing workflows

 Primary Care Practices

  • Enhanced Accessibility: Lower barriers for patient participation

  • Flexible Engagement: Support for varied patient monitoring patterns

  • Integration Opportunities: Better complement to existing chronic care management

 RPM Vendors

  • Market Expansion: Products could serve less-engaged patient populations

  • Product Development: Opportunity to design for shorter monitoring periods

  • Competitive Positioning: Early adoption of proposed code structures

Preparation Recommendations

Before Final Rule (Now - December 2025)

  • Patient Analysis: Health teams may want to consider auditing their current patient base to identify those who regularly fall short of the 16-day monitoring threshold or receive less than 20 minutes of monthly clinical engagement. These populations may soon be eligible for RPM which can be billed under the new rules

  • System Readiness: Prepare platforms to support proposed new codes

  • Staff Education: Begin training on potential new workflows

  • Public Comment: Consider submitting feedback during comment period

If/When Final Rule Published (Expected Late 2025)

  • Documentation Updates: Align clinical protocols with finalized codes

  • Patient Communication: Inform patients of any changes to monitoring requirements

  • Financial Modeling: Calculate potential revenue impact from expanded eligibility

Financial Projections (Hypothetical)

Note: These are estimates based on proposed changes, not guaranteed outcomes

For a practice with 1,000 chronic care patients:

  • Current Model: ~600 patients meet 16-day threshold

  • Proposed Model: Potentially 850+ patients could qualify under 2-day threshold

  • Estimated Impact: 25-40% increase in eligible patient population

For a detailed breakdown of current RPM pricing models and cost structures that form the baseline for these projections, see our comprehensive guide on Remote Patient Monitoring Pricing Structure and Models for Healthcare Providers.

Current Uncertainties

Key Questions Awaiting Final Rule:

  • Will reimbursement rates remain equal between 2-15 day and 16-30 day codes?

  • What documentation requirements will apply to shorter clinical interactions?

  • How will quality measures be adapted for more flexible monitoring?

Official Sources for Updates

  • CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-pfs-proposed-rule-cms-1832-p

  • Federal Register: https://www.federalregister.gov/documents/2025/07/16/2025-13271/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-schedule-and-other

  • CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-physician-payment-rule-significantly-cut-spending-waste-enhance-quality-measures-and

Conclusion

The proposed 2026 CMS changes represent a potentially significant expansion of RPM accessibility and reimbursement flexibility. However, healthcare organizations should:

  1. Monitor Final Rule Publication: Expected in late 2025

  2. Participate in Public Comment: Submit feedback by September 12, 2025

  3. Prepare Conditionally: Begin planning while awaiting final policy

  4. Stay Informed: Follow official CMS channels for updates

Remember: These are proposed changes subject to modification. Final implementation depends on CMS's review of public comments and publication of the final rule.

Document Status: Based on CMS Proposed Rule CMS-1832-P issued July 14, 2025
 last Updated: September 2025

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