Remote Patient Monitoring (RPM) Documentation Requirements

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Brief Description
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Practitioner, nurse, and ancillary progress notes
Documentation to support the following requirements:
  1. Identification of the acute or chronic condition being monitored
  2. Data collection for at least 16 days out of 30 days
  3. Medical necessity for monitoring
  4. Patient consent at the time RPM services are provided
  5. An internet-connected device used to collect and transmit data that meets the FDA definition of a medical device
  6. Live and interactive communication with the patient and/or caregiver related to RPM data
The following RPM components must be documented:
  1. Patient education and device setup: How to use the device and accurately collect data
  2. Device supply: How to connect the device so you can read results, and how often patients should use the device
  3. Treatment management: Reviewing patient data, decisions regarding treatment, and discussion with the patient
Medical record documentation to support time spent on services for the CPT level of code billed
Description of the non-face-to-face- services provided
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Documentation supporting the diagnosis code(s) required for the item(s) billed
Documentation to support the code(s) and modifier(s) billed
List of all non-standard abbreviations or acronyms used, including definitions
Any other supporting/pertinent documentation
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
Signatures are required for medical review for the following purposes: 1) To satisfy specific signature requirements in statute, regulation, National Coverage Determination (NCD) or Local Coverage Determination (LCD); and 2) To resolve authenticity concerns related to legitimacy of falsity of the documentation
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider/supplier compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Radiation Oncology webpage for additional information and resources.

Last Updated Jun 19 , 2025