We recently did a deep dive into CMS's proposed creation of an Advanced Primary Care Management (APCM) program. While this is one of the most significant proposals concerning remote care management included in the 2025 physician fee schedule (PFS) proposed rule, CMS is considering other changes that could greatly reshape the delivery of remote care management and development of remote care programs.
In this post, we explore five of the other biggest remote care management changes under consideration for the new year.
Note: To learn more about the significant remote care management developments from this year's PFS proposed rule, watch "Understanding Medicare's 2025 Proposed Changes to Remote Care Management," the on-demand webinar now available from Prevounce.
In last year's physician fee schedule 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 — e.g., chronic care management (CCM), principal care management (PCM), behavioral health integration (BHI) — already billable through G0511.
Under these new rules, G0511 could be billed multiple times per patient, per month based on the mix of services provided. However, this caused considerable billing confusion.
To seemingly help clear up the confusion, CMS is proposing in the 2025 PFS proposed 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 also 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 will remove this incentive and place the emphasis on ensuring patients receive appropriate services, regardless of the time required.
The proposed payments for FQHC and RHC care management services would be at the national non-facility Medicare payment rate.
What would 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 proposed revised rules lower the reimbursement floor but raise the payment ceiling for FQHCs and RHCs billing RPM and CCM.
CMS is proposing payment starting in 2025 for the use of Digital Mental Health Treatment (DMHT) devices as part of behavioral health treatment. DMHT devices are defined by CMS in the PFS rule as "…software devices cleared by the FDA that are intended to treat or alleviate a mental health condition, in conjunction with ongoing behavioral health care treatment."
The use of DMHT would be billable through three new HCPCS codes:
The services codes — GMBT2 and GMBT3 — would be cross-walked to existing RTM CPT services codes 98980 and 98981.
The requirement for the DMHT device to be "FDA cleared" would restrict the utilization of the codeset to devices that have gone through a pre-market or 510(k) approval. There are currently about 30 cleared digital therapeutic products that might qualify.
In the 2025 proposed rule, CMS asks for comments regarding which cleared devices should be reimbursable under these new codes as well as questions like:
The 2024 PFS introduced billing codes for caregiver training. This meant eligible providers could bill for the service of training caregivers to help with activities of daily life like feeding, bathing, and behavior management.
For 2025, CMS has proposed new HCPCS codes and reimbursement for caregiver training to now perform medical tasks. Topics of trainings could include decubitus ulcer formation, infection control, and wound dressing changes.
CMS has also proposed new coding and reimbursement for caregiver behavior management and modification training. These services, which would require a patient's or representative's consent, could be furnished to the caregiver(s) of an individual patient and provided via telehealth.
In the 2024 PFS final rule, CMS finalized codes and payment methods for community health integration (CHI) services, principal illness navigation (PIN) services, and social determinants of health (SDOH) risk assessment.
In the 2025 proposed rule, CMS declared it is seeking comments on a number of issues concerning these risk assessment and social needs services:
CMS is proposing permanent coverage of two-way, real-time, audio-only telehealth services (e.g., telephone) specifically for "... any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system but the patient is not capable of, or does not consent to, the use of video technology." Such changes would enable providers to expand treatment services in rural and remote areas, which often have limited broadband.
This is potentially great news for patients who cannot currently access audio-video telemedicine. In addition, this proposal, if approved, would keep the flexibility for providers to use audio-only telehealth services but implies that the default should be audio-video services unless there is a valid reason. Until CMS provides additional clarity around these rules, providers should document when and why they chose to deliver audio-only telehealth.
It's clear that remote care management is rapidly evolving, and there's every reason to believe that we will continue to see significant changes to the various remote care services for years to come. Prevounce has earned its reputation as leader in helping providers launch and grow remote care management programs by staying current on the latest news, trends, and developments. This knowledge helps ensure Prevounce's technology and support keeps clients compliant with evolving regulations, which translates to thriving remote care programs that follow rules, maximize patient engagement and satisfaction, and do not leave money on the table.
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