In the 2024 physician fee schedule (PFS) final rule, CMS added remote patient monitoring (RPM) and remote therapeutic monitoring (RTM) as services billable by federally qualified health centers (FQHCs) and rural health clinics (RHCs) under HCPCS G0511. For 2024, RPM and RTM joined a host of other care management services already billable through G0511, such as chronic care management (CCM).
Under the 2024 rules, G0511 could be billed multiple times per patient, per month based on the mix of services provided. However, this caused considerable billing confusion for many. CMS has, in turn, has revised and clarified FQHC and RHC billing guidelines in the newly-released 2025 PFS final rule.
Unbundling of Care Management Codes
To seemingly help clear up the confusion, CMS has finalized its plans, through the 2025 PFS final rule, to break up G0511 and instead allow FQHCs and RHCs to use existing care management CPT codes to bill for care management services.
This should encourage FQHCs and RHCs to allocate more time for care management services like RPM and CCM. Patients in these settings are more likely to need additional care management time, but the existing coding scheme incentivized providers to limit care management services to 20 minutes. Enabling FQHCs and RHCs to use existing care management CPT codes for billing removes this incentive and place the emphasis on ensuring patients receive appropriate services, regardless of the time required.
There will be a need for greater precision in the delivery of care management services, but also the potential for more revenue. CMS is allowing for a 6-month adjustment period.
Realignment With Non-Facility Rates
The payments for FQHC and RHC care management services will be at the national non-facility Medicare payment rate.
What does this new FQHC and RHC care management coding and billing scenario look like? FQHCs and RHCs billing RPM and CCM are paid about $146 per patient per month in 2024.
Compare that to non-FQHCs/RHCs, which can bill up to $202 per patient per month in 2024.
The revised rules lower the reimbursement floor — 20 minutes of care management pays less with the unbundling — but raises the payment ceiling for FQHCs and RHCs billing RPM and CCM.
New Advanced Primary Care Management Services
Through the 2025 PFS final rule, CMS is also creating new codes and payments for Advanced Primary Care Management services (APCM) that can be used by FQHCs and RHCs. APCM is Medicare's newest initiative intended to help providers deliver continuous, proactive care to patients with chronic conditions. Three new HCPCS G-codes bundle elements of several existing care management and communication technology-based services, like comprehensive patient assessments, development of a personalized care plan, ongoing care coordination, non-visit-based care, and the use of technology systems to document and support these efforts. The new HCPCS codes are as follows:
- G0556 is for patients with up to one chronic condition.
- G0557 is for patients with multiple chronic conditions.
- G0558 is for high-complexity patients with Qualified Medicare Beneficiary (QMB) status and multiple chronic conditions.
The bundles reflect the essential elements of the delivery of advanced primary care, including CCM, principal care management, and transitional care management. FQHCs and RHCs can provide and bill for APCM while still using RPM.
Care Management Technology Implications
Given these substantial changes, it is imperative that FQHCs and RHCs ensure the technology vendor they use to document and bill for care management services is keeping current with these changes and the many others included in the final rule and other recent announcements.
Learn More During our November 19 Final Rule Webinar
If your FQHC or RHC already provides or is considering delivering care management services, get more information on the changes noted above, other key takeaways from the final rule, ramifications of the Office of Inspector General RPM report, and the steps you should consider taking in our webinar, "Understanding Medicare's 2025 Changes to Remote Care Management," on November 19 at 2:00 PM ET / 11 AM PT. Sign up for this can't-miss program today!