Billing & Revenue Engine

Vantrexia's billing engine automates the entire RPM revenue cycle — from identifying billable activities to generating claims, tracking submissions, and producing analytics reports. The system supports all CMS-recognized RPM CPT codes and handles multiple billing sources including device transmissions, clinical escalations, and manual time entries.

RPM CPT Codes & Reimbursement Rates

Vantrexia supports the full range of CMS RPM and CCM billing codes. Reimbursement rates shown are 2026 Medicare national averages — actual rates vary by payer and locality.

Billing Sources

Vantrexia captures billable activities from four distinct sources, each generating billing records automatically:

1. Automatic Device Billing

A Celery task runs daily at 2:00 AM to evaluate device transmission compliance. For each patient who has met the 16-day transmission requirement during their current 30-day billing period, the system automatically generates a CPT 99454 billing record.

@shared_task(name='billing.generate_device_billing')
def generate_device_billing():
    """
    Runs daily at 2:00 AM via Celery Beat.
    Generates CPT 99454 records for patients meeting
    the 16-day transmission threshold.
    """
    today = timezone.now().date()
    active_patients = Patient.objects.filter(
        active=True,
        devices__isnull=False
    ).distinct()

    created_count = 0
    for patient in active_patients:
        period_start = patient.current_billing_period_start
        period_end = period_start + timedelta(days=30)

        if today < period_end:
            continue  # Period not yet complete

        transmission_days = Observation.objects.filter(
            patient=patient,
            effective_datetime__date__gte=period_start,
            effective_datetime__date__lt=period_end
        ).values('effective_datetime__date').distinct().count()

        if transmission_days >= 16:
            BillingRecord.objects.get_or_create(
                patient=patient,
                cpt_code='99454',
                service_date=period_end,
                billing_period_start=period_start,
                billing_period_end=period_end,
                defaults={
                    'amount': Decimal('43.02'),
                    'source': 'automatic_device',
                    'status': 'pending_review',
                    'transmission_days': transmission_days,
                }
            )
            created_count += 1

    logger.info(f"Device billing complete: {created_count} records created")

2. Escalation-Based Billing

When clinicians resolve escalation events, the system automatically logs the interaction time and generates billing records for CPT 99457 (first 20 minutes) and CPT 99458 (each additional 20 minutes). Time is tracked from escalation assignment to resolution.

3. MA Triage Billing

Medical Assistants who perform triage review and patient outreach generate billable time entries. The system tracks triage session duration and associates it with the appropriate CPT code based on cumulative monthly time per patient.

4. Manual Billing

For activities not captured automatically (e.g., CPT 99453 initial setup, CPT 99091 data interpretation), authorized users can create manual billing records through the billing interface or API. Manual records follow the same review and submission workflow as automatic records.

Smart Billing Engine

The smart billing engine runs every 4 hours via Celery Beat to identify and generate billing records for activities that may not be captured by the daily device billing task. It performs the following checks:

• Time accumulation: Aggregates clinical interaction time per patient per month from escalation events, triage sessions, and manual time entries. When cumulative time crosses a 20-minute threshold, a new CPT 99457 or 99458 record is generated.
• Missed device billing: Catches any patients whose billing period ended but were missed by the 2:00 AM task (e.g., due to task failure or late-arriving data).
• Duplicate detection: Prevents double-billing by checking for existing records with the same patient, CPT code, and billing period before creating new records.
• Eligibility validation: Verifies that patients meet CMS requirements for each CPT code before generating claims (active enrollment, valid consent, proper documentation).

Billing Claim Lifecycle

Every billing record progresses through a defined state machine. The lifecycle ensures proper review and documentation before claims are submitted to payers.

Report Endpoints

Vantrexia provides 13 built-in report endpoints that cover every aspect of billing analytics. All reports support date range filtering, CSV/PDF export, and role-based access control.

Revenue Calculator Example

Here is a sample calculation for a practice monitoring 500 patients, assuming typical compliance and utilization rates: