Is Your RTM Documentation Defensible? What Medicare Expects and Where Clinicians Get Tripped Up

Remote therapeutic monitoring (RTM) is a reimbursable, skilled physical therapy service—but only when documentation clearly demonstrates clinical intent, decision-making, and impact. Defensible documentation in RTM is the practice of clearly and consistently recording why RTM is clinically necessary, how it is being used, and how it influences patient care in a way that would stand up to payer review, audit, or appeal. 

Because RTM codes reimburse for care delivered outside the clinic walls, documentation must go beyond noting that data was collected. It must demonstrate skilled clinical judgment, active management, and a direct connection to the patient’s plan of care and goals. When documentation clearly links RTM activities to functional goals, treatment progression, and clinical reasoning, it protects providers, supports appropriate reimbursement, and reinforces RTM as skilled, billable care rather than background technology.

This guide outlines what physical therapists must document to support compliant, defensible RTM billing under Medicare, and how Medbridge helps make it easy for clinicians to bill for RTM without losing valuable care time with patients.

The following is based on APTA’s 2025 Practice Advisory. Coverage policies, payment rates, and payer decisions regarding RTM are subject to change. Commercial and Medicaid policies should always be verified directly with each payer prior to billing and all billing decisions remain the responsibility of the billing clinician and clinic.

Foundational Documentation Required for All RTM Services

The guidance from APTA is clear: RTM must be documented like any other skilled physical therapy intervention. Therapy clinicians can only bill RTM codes if they are part of a therapy plan of care. Clinicians should document progress toward established goals and what they hope to achieve using RTM. The RTM episode begins when the clinician turns it on and ends when the established goals in the patient’s care plan are met. Document that the patient has agreed to receive RTM services.

At a minimum, documentation should demonstrate:

• RTM is provided under an active, established plan of care

• The clinical purpose of RTM within that plan

• How RTM supports progress toward plan-of-care goals

• Clinical decision-making informed by RTM data

• Ongoing assessment of patient response to RTM-supported interventions
  

Plan-of-Care Goals

• Goals may or may not explicitly mention RTM

• Goals must clearly reflect what the therapist intends to achieve using RTM

• Goals do not need to include device setup or education as standalone objectives

Assistant Modifiers

Certain RTM codes are subject to the CQ/CO assistant modifier (de minimis/10% policy) when applicable (for 2026, CMS lists 98975, 98979, 98980, 98981 as in-scope). 98985 and 98977 are not subject to the rule.

Documentation Requirements for CPT Code 98975

(Initial Setup and Patient Education)

CPT 98975 is billed once per episode of care and requires documentation that supports both setup and education as skilled services.

Therapists must document:

• The type of RTM device used

• Confirmation that the device meets the FDA definition of a medical device

• The specific education and training provided to the patient and/or caregiver

• Any device setup activities performed

• Evidence that the patient activated and used the device

Documentation Requirements for CPT Code 98977 and 98985

(RTM Device Supply)

These codes cover the supply of RTM devices and require clear documentation of the device and monitoring period.

APTA requires documentation of:

• Name and description of the device

• The body system being monitored

  • 98977: Musculoskeletal

  • 98985: Musculoskeletal

• Confirmation that the device meets the FDA medical device definition

• 98977: Evidence of at least 16 days of data transmission within a 30-day period

• 98985: Evidence of 2-15 days of data transmission in a 30-day period

Documentation Requirements for CPT Codes 98979, 98980, and 98981

(RTM Treatment Management Time)

APTA is most explicit about documentation expectations for RTM treatment management. This is where skilled care must be unmistakable.

Therapists must document:

• Total minutes of RTM treatment management time in the calendar month

• That this time was spent reviewing RTM data and managing care

• Date and time of at least one interactive communication with the patient or caregiver

• The mode of communication (must be synchronous: phone, video, or in person)

• Clinical decisions or care plan changes made as a result of RTM data

• How RTM data influenced:

  • Treatment progression

  • Program modification

  • Reinforcement of current interventions

Key Billing Rules to Reinforce in Documentation

• Secure messaging and asynchronous communication do not qualify

• RTM time cannot be counted toward other billable services

• For 98979, each unit requires the first full ten minutes.

• For 98980 and 98981, each unit requires a full 20-minute increment.

Bottom Line: What Makes RTM Documentation Defensible

Defensible RTM documentation tells a clear story: RTM data was collected, interpreted by a skilled therapist, acted upon clinically, and used to move the patient toward meaningful goals.

When documentation consistently reflects that narrative, RTM becomes not only billable—but sustainable, scalable, and audit-ready. For more information, visit the following resources:

• The APTA’s 2026 Practice Advisory.

• The Medbridge Remote Therapeutic Monitoring Resource Center

• The American Physical Therapy Association (APTA) publishes a State Medicaid Payment Rate Guide that includes RTM rates for many states. 

How Medbridge Can Help

Medbridge One Care provides the right tools and workflows to make RTM documentation easy. One Care brings our RTM solution, Home Exercise Programs, Guided Pathways, and patient-reported outcomes together in a single connected platform, making it easy to enroll patients, deliver personalized programs, monitor progress between visits, and automatically track the activity and time needed for compliant documentation. By combining real-time engagement data with meaningful patient feedback, One Care helps clinicians adjust care more effectively, demonstrate the value of remote monitoring, and ultimately improve patient outcomes—without adding administrative burden.

To learn more about how Medbridge can help you simplify RTM billing, request a demo today.