Checklist: Remote therapeutic monitoring (RTM)
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for remote therapeutic monitoring (RTM) services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. | |
| Documentation is complete, legible, signed and dated by the physician or clinician. | |
| Documentation supports the medical necessity of RTM services. | |
| Order or plan of care supporting RTM services is documented when applicable. | |
| Patient consent is documented prior to initiation of RTM services (verbal or written, as allowed by Medicare policy). | |
| Diagnosis/condition being monitored is documented. | |
| Device use and monitoring period are documented and support the billed service (e.g., 98977) | |
| Interactive communication with the patient and/or caregiver is documented for CPT 98980 and 98981, as required. | |
| Total cumulative treatment management time is documented for CPT 98980 and 98981. | |
| Time logs or other documentation support the reported minutes for time-based RTM services. | |
| Documentation supports the use of an FDA-defined medical device that automatically collects and transmits therapeutic monitoring data. | |
| Review and assessment of transmitted therapeutic data is documented. | |
| Clinical interventions, treatment recommendations, and/or modifications to the treatment plan are documented. | |
| Documentation supports physician or qualified health care professional involvement in treatment management services. | |
| If applicable, an Advanced Beneficiary Notice (ABN) or other beneficiary waiver of liability is included. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determination, or the CMS documentation guidelines. It is responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.