Telehealth Implementation Playbook

Telehealth can be used as an alternative to traditional in-person care delivery and, in certain circumstances, can be used to deliver care such as the diagnosis, consultation, treatment, education, care management and self-management of patients.

Remote Patient Monitoring Implementation Playbook

​​​​​​​Remote patient monitoring (RPM) captures and records patient physiological data outside of the traditional health care environment. RPM provides the opportunity to improve diagnosis and management of chronic disease and engage patients in their own care.

Medicare Learning Network –
Chronic Care Management Services

CMS recognizes Chronic Care Management (CCM) is a critical primary care service that contributes to better patient health and care. This booklet provides background on payable CCM service codes, names eligible billing practitioners and patients, and details the Medicare Physician Fee Schedule (PFS) billing requirements. The Look-Up Tool has code-specific payment information by geographic location.

Medicare Learning Network –
Transition Care Management Services

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Agency for Healthcare Research and Quality – RPM 2023

RPM is a type of telehealth in which healthcare providers monitor patients outside the traditional care setting using digital medical devices, such as weight scales, blood pressure monitors, pulse oximeters, and blood glucose meters. The data collected from these devices are then electronically transferred to providers for care management. Automated workflows can be used to flag out-of-range values.

Could Wearables Capture Well-being? Icahn School of Medicine at Mount Sinai

According to Robert P. Hirten, MD, Clinical Director, individual’s Hasso Plattner Institute for Digital Health at Mount Sinai, “Wearables provide a means to continually collect information about an physical state. Our results provide insight into the feasibility of assessing psychological characteristics from this passively collected data,” More on the data and findings: JAMIA Open,


To offset rising costs, healthcare providers are empowering patients to play a more active role in monitoring their own health.
Remote Patient Monitoring (RPM) promotes vital tracking, early detection, and prevention of disease.

Currently, 57% of healthcare provider organizations already use RPM to monitor patients’ vital signs at home. And, by 2024, it’s estimated that 75% of US medical practices will use RPM services.
Source: Sage Growth Partners survey January 2022

2023 Complex Chronic Care Management CPT Codes

99487 Minimum 60 cumulative minutes over a 30-day period of non-face-to-face consultation time establishing or monitoring a care plan. $133.18
99489 To be billed with CPT 99487 for every additional 30 minutes of non-face-to-face consultation. $70.49

2023 Chronic Care Management CPT Codes

99490 Minimum 20 cumulative minutes over a 30-day period of non-face-to-face time monitoring the care plan. $62.69
99439 Subsequent 20 minutes of care provided by clinical staff. $47.44
99491 Initial 30 minutes of care personally provided by physician, or non-physician practitioner (NPP). $85.06
99437 Subsequent 30 minutes of care personally provided by a physician or NPP. $59.98

2023 Remote Patient Monitoring CPT Codes

99453 Initial set-up & patient education on equipment (one-time fee). $19.32
99454 Supply of devices, collection, transmission, and report/ summary of services to the clinician. $50.15
99457 Remote physiologic monitoring services by clinical staff/MD/ QHCP first 20 cumulative minutes of RPM services over a 30-day period. $48.80
99458 Remote physiologic monitoring services by clinical staff/MD/ QHCP for an additional cumulative 20 minutes of RPM services over a 30-day period. $39.65
99091 Collection and interpretation of data by physician or QHCP, 30 minutes. $54.22

2023 Transitional Care Management CPT Codes

99495 Transitional care mgmt, mod. complexity $205.36
99496 Transitional care mgmt, high. Complexity $278.21