Remote Patient Monitoring

POLICY

Certain service procedure codes are covered for remote patient monitoring (RPM) when specific medical necessity criteria are met.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 80-81 (Jul. 2025), WAC 182-551-2125(1). (Accessed Aug. 2025).

Home Health Services

The medicaid agency pays for one telemedicine interaction, per eligible client, per day, based on the ordering physician’s home health plan of care. To receive payment for the delivery of home health services through telemedicine, the services must involve:

(a) An assessment, problem identification, and evaluation which includes:

• Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also includes assessment of response to previous changes in the plan of care; and
• Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

(b) Implementation of a management plan through one or more of the following:

• Teaching regarding medication management, as appropriate;
• Teaching regarding other interventions as appropriate to both the patient and the caregiver;
• Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;
• Coordination of care with the ordering physician regarding findings;
• Coordination and referral to other medical providers as needed; and
• Referral to the emergency room as needed.

The medicaid agency does not require prior authorization for the delivery of home health services through telemedicine. The medicaid agency does not pay for the purchase, rental, or repair of telemedicine equipment. Electronic visit verification requirements are not applicable to home health services delivered through telemedicine. Other program rules may apply similar or the same record requirements to providers of home health services.

SOURCE: WAC 182-551-2125. (Accessed Aug. 2025).

HCA covers the delivery of home health services through telemedicine for clients who have been diagnosed with an unstable condition who may be at risk for hospitalization or a more costly level of care.  See manual for codes.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28-30. (Jul. 2024). (Accessed Aug. 2025).

CONDITIONS

Specific medical necessity criteria must be met for RPM coverage, including disease-specific criteria. In addition to meeting other defined general criteria, the client must have a qualifying diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or hypertension.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 80-81. (Jul. 2025). (Accessed Aug. 2025).

Home Health Services

The client must have a diagnosis or diagnoses where there is a high risk of sudden change in medical condition which could compromise health outcomes. See manual for specific codes to bill.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28. (Jul. 2024). (Accessed Aug. 2025).

PROVIDER LIMITATIONS

FQHCs/RHCs

CPT® code 99453 is encounter-eligible when performed by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) encounter-qualified provider. Other RPM procedure codes are not RHC- or FQHC-encounter eligible.

IHS Clinics, Tribal Clinics, and Tribal FQHCs

Direct Indian Health Service (IHS) Clinics, Tribal Clinics, and Tribal FQHCs— refer to HCA’s Tribal Health Billing Guide to determine if the service qualifies for the IHS encounter rate.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 81 (Jul. 2025). (Accessed Aug. 2025).

OTHER RESTRICTIONS

Specific medical necessity criteria must be met for RPM coverage, including the following:

• Client-specific criteria. The client must exhibit at least one of the following risk factors in each category:
  • Health care utilization:
    • Two or more hospitalizations in the prior 12-month period
    • Four or more emergency department admissions in the prior 12-month period
  • Other risk factors that present challenges to optimal care:
    • Limited or absent informal support systems
    • Living alone or being home alone for extended periods of time
    • A history of care access challenges
    • A history of consistently missed appointments with health care providers
• Device-specific criteria. The device must have both of the following:
  • Capability to directly transmit patient data to provider
  • An internet connection and capability to use monitoring tools

Informed consent documentation requirements and quantitative limits also apply to RPM services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 80-81 (Jul. 2025). (Accessed Aug. 2025).

Home Health Services

HCA pays for one telemedicine interaction, per eligible client, per day, based on the ordering licensed practitioner’s home health plan of care.

To receive payment for the delivery of home health services through telemedicine, the services must involve:

• A documented assessment, identified problem, and evaluation, which includes:
  • Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also included is an assessment of response to previous changes in the plan of care.
  • Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care

• Implementation of a documented management plan through one or
  more of the following:
  • Education regarding medication management as appropriate, based on the findings from the telemedicine encounter
  • Education regarding other interventions as appropriate to both the patient and the caregiver
  • Management and evaluation of the plan of care, including changes in visit frequency or the addition of other skilled services
  • Coordination of care with the ordering licensed provider regarding findings from the telemedicine encounter
  • Coordination and referral to other medical providers as needed
  • Referral to the emergency room as needed

HCA does not pay for the purchase, rental, repair, or maintenance of telemedicine equipment and associated costs of operation of telemedicine equipment.

HCA does not require prior authorization for the delivery of home health services through telemedicine.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 29. (Jul. 2024). (Accessed Aug. 2025).