Chronic conditions continue to grow in the U.S, with 64% of Medicare Advantage and 60% of fee-for-service Medicare beneficiaries having three or more chronic conditions. Chronic care management (CCM) helps address challenges with personalized support beyond office visits. By using remote patient monitoring (RPM) in chronic care management, health teams can be more preventive with care, increase engagement, reduce costs, and increase revenue. Together, activating RPM in CCM is a whole approach to managing chronic conditions.
This article will walk you through how using RPM with CCM may be beneficial to a chronic care practice.
Why Activating RPM in CCM Adds
One of the most persistent gaps in healthcare is monitoring patients’ progress between appointments. Activating remote patient monitoring in chronic care management gives providers a patient’s health data between appointments. CCM provides structure and accountability for patients with multiple chronic conditions, while RPM data turns that structure into action.
Remote patient monitoring continues to grow in adoption, with Medicare payments for RPM exceeding $500 million in 2014. Additionally, a 2024 Value in Health review found that remote monitoring is cost-effective across cardiovascular and metabolic conditions by reducing hospitalizations and emergency visits. When RPM is combined with CCM’s ongoing coordination, those savings can expand into long-term financial sustainability.
How to Activate RPM Within CCM
The process of activating remote patient monitoring in chronic care management begins with patients who are currently enrolled in a CCM program. Because these individuals are commonly managing hypertension, COPD, diabetes, or heart failure, they may be candidates for continuous data monitoring.
To activate RPM, a CCM practice would first follow these three steps:
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Identify the patients who may benefit from RPM. Focus on those who experience fluctuating symptoms or frequent medication adjustments.
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Select RPM devices that align with the conditions managed. Cellular-connected blood pressure monitors, weight scales, glucose meters, and pulse oximeters are among the most common.
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Establish data integration. Device readings should automatically sync to a care management platform or EHR. This allows care teams to view data trends, flag anomalies, and document interventions within the same workflow.
Integration is the most critical and potentially most challenging step. One literature review showed that 83% of remote monitoring implementation barriers are related to workflow and system integration. Therefore, investing early in a system that supports interoperability prevents data silos and manual tracking later. Once solid workflows are in place, it is important to build a rhythm between RPM data review and CCM touchpoints.
For instance, care coordinators can monitor daily readings. Any concerning trends can be escalated to clinical staff. This continuous feedback loop helps patients feel supported. It also gives providers a clearer picture of disease progression in real time.
Reimbursement and Compliance Advantages
Under today’s CMS rules, one of the strongest arguments for activating RPM within CCM is financial sustainability. CMS allows RPM and CCM to be billed in the same month if each service independently meets its requirements and time is not double-counted. RPM uses CPT code 99453 for setup and education, CPT 99454 for device supply and collection. RPM CPTs 99457 and 99458 are for time-based monitoring and management.
CCM commonly uses CPT 99490 and 99439 for care coordination. This pairing is intentional because RPM supplies real-time physiologic data and CCM operationalizes behavior change and coordination and follow through around that data.
Oversight in 2026 is Tightening
As previously mentioned, Medicare payments for RPM exceeded $500 million in 2024 and CMS will heighten safeguards so all required components are furnished and billed appropriately. This means appropriate tracking of services and billing is aboslutely necessary.
CMS 2026 Physician Fee Schedule Proposed Rule signals two notable changes for remote monitoring:
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How rates are set: CMS proposes using hospital outpatient cost data to help set practice-expense values for some remote monitoring services. This shift is meant to ground prices in auditable, routinely updated hospital data.
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More flexible monitoring windows: CMS proposes new remote monitoring codes for 2–15 days of data in a 30-day period, alongside keeping the existing 16–30 day pathway for flexibility rather than repealing the 16-day option.
2025 vs. 2026 Proposed RPM and CCM Billing
The CMS 2026 Proposed Rule, suggests adjustments “for some remote monitoring services,” and introducing new codes for 2–15 days of data collection in a 30-day period.
The “16-day” requirement remains in effect today for the RPM device supply code 99454 and for 99453 setup and education. Therefore, 16 days of patient-generated data in a 30-day period is needed to bill 99454. The 16-day threshold does not apply to the time-based 99457 and 99458.
The Clinical and Financial Impact
In the AMA’s Return on Health case study of a large hypertension program, organizations realized $77 per member per month in savings compared with usual care. In a separate report from the American Medical Association, ROI averaged 22.2% at 55% patient compliance for an RPM cardiology program with 100 patients.
Beyond, the financial impact, patients can become more engaged in their care. Seeing their own blood pressure trends, improvement or weight stabilization builds motivation and reinforces adherence. Providers, meanwhile, benefit from continuous insight into what’s working, which medications need adjustment, and which patients need extra outreach before they deteriorate.
In short: RPM makes CCM smarter. Instead of relying solely on self-reported information or monthly calls, teams can act based on real-time evidence.
A Whole Approach to Preventive Care
Activating remote patient monitoring in chronic care management allows healthcare organizations to move from reactive to proactive management. For patients living with multiple chronic conditions, that shift can mean fewer hospital visits, greater independence, and a sense of partnership in their care. For providers, it can mean better outcomes, improved quality scores, and a stronger financial foundation for long-term program growth.
If your CCM program is already established, adding RPM can add on a next level of connected care. To learn more about activating RPM, request a free demo of Tenovi’s RPM and RTM solutions.
