Remote Patient Monitoring

POLICY

Effective October 1, 2023, South Dakota Medicaid added permanent coverage of remote patient monitoring of physiologic functions when medically necessary for recipients with acute or chronic conditions when ordered and billed by providers who are eligible to bill Medicaid for E/M services. Certain criteria must be met (see below).

See table on page 7-9 for eligible codes.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Feb. 2025) (Accessed Apr. 2025).

The Office of Adult Services and Aging 

“Telehealth services,” a home based health monitoring system used to collect and transmit an individual’s clinical data for monitoring and interpretation.

SOURCE: SD Regulation 67:40:19:01(21) (Accessed Apr. 2025).

Home Health

For the initial order for home health services, a physician or other licensed practitioner must document a face-to-face encounter related to the primary reason the beneficiary requires the services. The encounter may occur through telemedicine. The encounter must occur within the 90 days before or 30 days after the start of the services

SOURCE: SD Medicaid Billing and Policy Manual: Home Health Services, p. 2 (Feb. 2024). (Accessed Apr. 2025).

Continuous Glucose Monitoring

South Dakota Medicaid covers continuous 72-hour glucose monitoring provided by an endocrinologist or an advanced practice provider working with an endocrinologist through the endocrinologist’s office no more than twice annually with a prior authorization.

SOURCE: SD Medicaid Billing and Policy Manual: Physician Services, p. 9 (Feb. 2025), (Accessed Apr. 2025).

CONDITIONS

The recipient must be diagnosed with at least one of the following conditions:

• Asthma
• Congestive Heart Failure
• Cardiac monitoring
• Hypertension or Hypotension
• Chronic Obstructive Pulmonary Disease
• Diabetes
• Gestational Diabetes
• COVID-19 post infection monitoring

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, pg. 6 (Feb. 2025) (Accessed Apr. 2025).

PROVIDER LIMITATIONS

Only a physician, physician assistant, nurse practitioner, or certified nurse midwife are allowed to order RPM and bill for the services.

FQHC/RHC

FQHC/RHC providers may bill for these services on a fee for service basis using their non-Prospective Payment System (PPS) NPI if the service is ordered by one of the allowable practitioner types.

IHS and Tribal 638

IHS and Tribal 638 facilities can bill the encounter rate for remote patient monitoring CPT codes 99091, 99457, and 99458 as long as these services meet the definition of an encounter and are in accordance with the “Four Walls” requirement under 42 CFR 440.90 as provided in the IHS and Tribal 638 Facilities manual.

School District Services

School district providers may provide physical and occupational therapy via telemedicine using CPT code 97799 for physical therapy and CPT code 97139 for occupational therapy. Speech-language pathology services continue to be allowed when provided via telemedicine and should be billed using CPT code 92507. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.

Psychology services may also be provided via telemedicine or real time, two-way audio-only using CPT code 90899. Audio-only services must be provided in accordance with the independent mental health practitioner coverage criteria stated in this manual.

Please refer to the School District Services manual for additional coverage information.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Feb. 2025) (Accessed Apr. 2025).

OTHER RESTRICTIONS

The recipient must be cognitively capable of operating the remote monitoring equipment or must be assisted by a caregiver capable of operating the equipment.

The recipient’s condition must be unmanaged or require frequent and on-going monitoring during a period where:

• The recipient is newly diagnosed with the condition in the last 6 months and is learning to manage the condition;
• The recipient has a chronic condition that has become difficult to manage in the last 6 months; or
• The recipient has had 2 or more episodes that required either emergency department care, hospitalization, or emergency intervention in the last 6 months.

The medical device supplied to a recipient as part of RPM services must be a medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, that the device must be reliable and valid, and that the data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.

RPM is only allowed for established patients who are under the active care of a provider.

The provider must document the medical necessity of the service.

The provider must obtain consent from the recipient to furnish RPM services.

The provider must prescribe a care plan that denotes the need for remote monitoring and the impact on treatment and management of the recipient . The care plan must also address actions taken by the provider and/or care team to improve or address the recipient’s ability to self manage the condition including patient education.

Prior Authorization

The out-of-state prior authorization requirement does not apply if the recipient is located in South Dakota at the time of the service and the provider is located outside of the State. If the service otherwise requires a prior authorization, the provider is still required to obtain prior authorization prior to providing the service.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Feb. 2025), (Accessed Apr. 2025).