Before going live with SaRA, there are four documentation updates to make to your EMR templates. They ensure proper justification and billing for Remote Therapeutic Monitoring (RTM).
1. Add RTM procedural codes to your evaluation template
Add the RTM codes to the list of codes you may bill during the plan of care: 98975, 98985, 98977, 98979, 98980, 98981. Adding them to the evaluation template means they appear in every initial evaluation.
2. Include RTM goal(s)
Create patient-specific goals that justify RTM as part of the plan of care. Examples:
"Patient will respond to >50% of RTM messages via SaRA Health to ensure increased compliance and quality of their HEP performance."
"Patient will respond to >50% of RTM messages via SaRA Health to assure the provider team has sufficient insight to modify the POC as needed."
3. Add a statement of medical necessity
Include this statement in your evaluation template:
"Due to the dynamic nature of the patient's condition, it is beneficial to have awareness of the changes in the patient's status between visits. Responses will be regularly reviewed to enable early intervention and reduce the likelihood of an unnecessary decline in status."
4. Update follow-up visit (daily/SOAP note) templates
Add a "Remote Therapeutic Monitoring (RTM)" section — best placed in the Subjective section, with optional reinforcement in Assessment. Suggested fields:
Confirmation of RTM review (checkbox or Yes/No): "RTM data reviewed with patient since last visit."
This one carries more weight than it looks. Reviewing the patient's RTM responses with them during the visit is exactly what counts as a synchronous interaction — the requirement for the treatment-management codes (98979/98980/98981). Checking this box is you documenting that the conversation happened.Patient response summary (short free text): "Summary of patient-reported responses to SaRA Health messages (pain, symptoms, progress, questions)." Example entry: "Patient reports decreased pain scores during the week and improved tolerance to HEP. Noted increased soreness after prolonged sitting."
Engagement / adherence (dropdown or checkboxes): Consistent / Intermittent / Limited / Not completed.
Issues or flags identified (checkbox + optional text): No issues / Pain increase / Functional limitation / Questions about exercises / Other.
Optional Assessment reinforcement (a single, audit-friendly checkbox): "RTM data reviewed and incorporated into clinical decision-making."
What NOT to do
Do not reference CPT codes by number in the note.
Do not claim continuous monitoring.
Do not auto-populate or carry forward RTM text without review.
Why this matters
Clinically: captures patient progress between visits more accurately than a single in-clinic snapshot.
Documentation: shows active data review and clinical relevance.
Efficiency: typically takes under a minute and replaces informal "How did the week go?" conversations with consistent documentation.