Remote patient monitoring
Between visits, your patients are still your patients.
22RPM enrolls your patients on connected home devices, receives their readings as they’re taken, and handles the daily review, escalation and documentation that remote monitoring requires.
What we do
What the service actually includes.
Six things, run by our team rather than added to yours — from getting the patient enrolled to getting the month billed.
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Automated billing
Billable time and transmission days are captured as the work happens, so the minutes behind a code trace to specific work. A dedicated billing team stands behind it.
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Dashboard and web app
The clinic gets its own login. Readings, review history and documentation are visible whenever you want them, rather than arriving as a periodic report.
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Patient registration
We enroll the patient ourselves — consent, paperwork and onboarding. It does not land on your front desk.
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Device setup
Devices arrive configured. The patient pairs one to their phone and starts taking readings; there is nothing for your staff to assemble.
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Patient engagement
Most remote monitoring ships a device and leaves adherence to chance. We do not. Our care team calls patients when readings call for it — so readings keep coming, and someone notices when they stop.
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Clinical review and documentation
Readings are reviewed daily. Anything outside a patient’s thresholds is escalated to you, and the month’s activity is documented as it happens.
The gap
Between appointments, most chronic disease goes unobserved.
A patient with hypertension or chronic kidney disease may be seen every three months. In between, their blood pressure is whatever it is — unrecorded, and invisible to the people responsible for managing it.
Readings arrive as anecdotes
A number recalled at the visit, or a handwritten log filled in from memory, is difficult to act on with any confidence.
Deterioration is found late
A trend that builds over weeks is usually only discovered at the next appointment, or in an emergency department.
The work has nowhere to live
Reviewing readings, calling patients and recording that time is real clinical work, and rarely has a place in the ordinary visit workflow.
Dialysis
Dialysis covers three days a week. Monitoring covers the other four.
For dialysis clinics, 22RPM provides a comprehensive at-home monitoring program for the days your patients are not in the chair.
An in-center patient is seen three times a week. The care model has no window into the other four days, and interdialytic weight gain and blood pressure are exactly what build during them — out of view until the next session.
We close that window: readings taken at home, reviewed by our clinical team, and escalated to your clinic with the context attached.
- Between sessions Readings are taken at home on the days the patient is not in the chair, on the same connected devices used across the program.
- Reviewed, not just collected Our clinical team looks at what comes in, contacts the patient when something is off, and records the time and the note behind it.
- Escalated to the clinic When a reading or a trend needs your team's attention, it reaches them with the context attached rather than as a raw alert.
How it works
Four steps, and only the first involves your staff.
Once a patient is enrolled, the monitoring runs without adding work to your front desk or your clinic day.
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Enroll
You identify eligible patients. We handle consent, explain the program, and set expectations for how often to measure.
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Device ships
A monitor is sent to the patient’s home, and we walk them through installing the 22RPM app and pairing the two. Our patient guide covers every step, in English and Spanish.
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Readings transmit
The patient measures as directed. Each reading reaches their care team through the app on its own — there is nothing to write down, and nothing to send.
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We review, escalate, document
Our clinical team reviews incoming readings, contacts patients when values fall outside range, escalates to you when it matters, and records the time and the clinical note behind every interaction.
You stay the treating clinician. We monitor, contact and document; decisions about diagnosis, medication and treatment remain yours.
What we monitor
Blood pressure, pulse oximetry, weight and ECG.
We support a deliberately narrow set of measurements, so that the review workflow behind them is thorough rather than broad.
Blood pressure
Systolic and diastolic pressure with pulse rate, captured on a connected upper-arm monitor. This is the core of the program and the measurement most of our patients are enrolled for.
Pulse oximetry
Peripheral oxygen saturation (SpO2) with pulse rate, for patients whose care plan calls for it.
Weight
Daily weight on a connected scale, for patients where fluid status matters to the care plan.
ECG
Single-lead ECG on a handheld recorder, for patients whose clinician has asked for rhythm capture.
If your patients need a measurement that is not listed here, ask us before you assume it is available — we would rather tell you no than enroll a patient we cannot properly monitor.
Who it’s for
Practices where blood pressure control changes the outcome.
The program suits clinicians who already manage blood pressure as a core part of the care plan, and who need to see it between visits.
Nephrology and dialysis
Blood pressure is central to slowing progression in chronic kidney disease and to managing patients after transplant. For patients on dialysis, interdialytic readings taken at home add context that in-center measurements alone do not provide.
Primary care
Hypertension is managed largely between visits, across a panel too large to follow up by phone.
Cardiology
Home readings give a fuller picture than a clinic cuff, particularly while titrating medication.
Billing & reimbursement
The RPM codes, in plain terms.
Medicare reimburses remote physiologic monitoring through a small set of CPT codes. Each one pays for a different part of the work, and each has its own threshold that must actually be met.
| Code | What it covers | Threshold |
|---|---|---|
| 99453 | Setting the patient up on the device and teaching them to use it. | One-time |
| 99454 | Supplying the device and collecting the readings it sends. | 16 or more transmission days |
| 99445 | The shorter-period equivalent of 99454. A month with fewer than two transmission days is not billable at all. | 2–15 transmission days |
| 99457 | Clinical staff time reviewing data and managing the patient. Requires interactive communication with the patient during the month. | First 20 minutes |
| 99458 | Added once for each further complete block of management time beyond the first. | Each additional 20 minutes |
| 99470 | The shorter-period equivalent of 99457. Not billed alongside it. | 10–19 minutes |
We do not publish figures or revenue projections. Payment rates vary by payer, locality and year, and eligibility depends on the patient and on thresholds genuinely being met. Our system tracks transmission days and management minutes against these rules so that what is billed reflects what was actually done. Confirm coverage and current rates with your payers and your own billing advisers.
Compliance
Handling patient data.
HIPAA
We operate as a business associate to the practices we serve, and handle protected health information under HIPAA.
Business associate agreement
A BAA is executed with your organization before any patient information is exchanged. Ask us for a copy to review.
Access and audit
Access to patient records is limited to the clinicians and staff assigned to that patient, and access is logged.
Questions about data handling, retention, or your BAA are answered directly — write to info@twentytwohealth.com.
Next step
Tell us about your patients.
The useful first conversation is a short one: which conditions you manage, roughly how many patients you would consider enrolling, and what you want monitoring to change.