REIMBURSEMENT TREE DOWNLOAD: https://caresimple.com/rpm-billing-guide-for-2025/
The 2025 Physician Fee Schedule Final Rule by CMS brings changes that will positively impact the growth and adoption of remote care management services for 2025 by both making it simpler and extending to FQHCs and RHCs.
The changes are outlined in two main areas:
- New codes for Advanced Primary Care Management (APCM) services
- Applying the full suite of distinct service-based billing codes for FQHCs and RHCs
ADVANCED PRIMARY CARE MANAGEMENT (APCM) SERVICES
In a departure from a focus on billing codes tied to transactional-based services, CMS has introduced new billing codes for Advanced Primary Care Management (APCM) services designed to encourage a more comprehensive and value-centric approach to patient care management. The new APCM billing codes incorporate elements from existing CMS defined services including Chronic Care Management (CCM), Principal Care Management (PCM), and Transitional Care Management (TCM).
However, in a major shift from time requirement rules in these codes, there are no time threshold or tracking requirements for APCM. The APCM codes are divided into three levels as summarized in the table below.
|
HCPCS Code |
Description |
Monthly Rate |
|
G0556 (Level 1) |
Clinical staff provides services meeting all the required elements of APCM services, for any patient, under guidance of a physician or qualified health professional responsible for the patient’s primary care needs |
$15.20 |
|
G0557 (Level 2) |
Services as described in G0556, for a patient with at least two chronic conditions expected to last at least 12 months, or until the death of the patient |
$48.84 |
|
G0558 (Level 3) |
Services as described in G0557 for a patient that is a Qualified Medicare Beneficiary |
$107.07 |
CMS requires several elements to be in place for the billing of APCM codes, which comprise a patient-centric comprehensive care management and care coordination plan, along with a practice population analysis and risk stratification assessment.
The new APCM codes aim to decrease the administrative burden by simplifying the requirements for monthly services and billing. While practices must be capable of providing all the required service elements, not every element must be delivered each month. This flexibility allows practices to tailor services based on patient need rather than focusing on the number of minutes spent by clinicians on care management.
CMS has identified services and related billing codes that overlap substantially with APCM services and therefore are not allowed to be billed in the same period as APCM. These include CCM, PCM and TCM, as well as specified communication-based technology CPT codes such as virtual check-ins. However other services viewed as complementary, such as RPM and RTM, can be billed concurrently in the same month as APCM codes.
With these new APCM services and reimbursement codes, CMS is opening the door for an enticing opportunity for primary care practices to embrace a transition to value based care using new care models based on enhanced digital health and communications technology.
FULL SUITE OF DISTINCT SERVICE-BASED BILLING CODES FOR FQHCS AND RHCS
A significant change for 2025 is the move to universally apply the full suite of distinct CMS defined billing codes for RPM services (RPM, RTM, CCM, PCM) to all provider types, including FQHCs and RHCs. This is a change from 2024 where FQHCs and RHCs[1] were required to use the general services code, G0511, as a catch-all code for all RPM services. While this code had the attraction of a higher per transaction reimbursement rate than the corresponding underlying RPM services, there was considerable confusion and delays in processing and reimbursement. This was due to a lack of clarity and transparency as to what specific underlying services were being performed under each general billing code submission.
The good news is that FQHCs and RHCs will now have much greater certainty and confidence in billing for the full range of RPM services using codes that have been in place for all provider types for several years. Additionally, this new change opens up the ability for FQHCs and RHCs to use billing code 99458 to bill for the additional 20-minute staff time periods allowable per month beyond the prior limit of 20 minutes per month (under 99457).
For a detailed list of billing codes and rates for RPM and related services, please refer to our widely regarded CareSimple Reimbursement Tree, updated for 2025: https://caresimple.com/rpm-billing-guide-for-2025/
The content provided in this article is intended for informational purposes only. Please seek advice from a CMS billing professional for precise guidance.
[1] As a reference on the previous codes for FQHCs and RHCs, see our Special Edition of the 2024 Billing Guide: https://caresimple.com/rhc-fqhc-rpm-billing-guide-for-2024/