As we prepare to ring in a new year, 2025 will see some big changes for healthcare providers in terms of CMS billing requirements. The Centers for Medicare & Medicaid Services (CMS) announced new rules for RHCs and FQHCs, as well as new APCM codes designed to support value-based care.

The American Medical Association (AMA) also made waves with a game-changing announcement regarding patient readings requirements for RPM billings.

CMS Moves Toward Value-Based Care with New APCM Codes for 2025

In an effort to expand primary care services and support practices as they move toward value-based care, the 2025 Medicare Physician Fee Schedule will include new Advanced Primary Care Management (APCM) codes.

Practices must be able to provide all 13 APCM service elements, but do not have to deliver every element every month. APCM billing may be submitted along with RPM services, but not with CCM services.

The new codes are:

HCPCS Code G0556

Patients with one chronic condition may receive APCM services from clinical staff under the direction of a physician or other qualified healthcare professional.

Reimbursement Rate: $15 (approximately)

HCPCS Code G0557

Patients with two or more chronic conditions that are expected to last at least 12 months (or until death of the patient) may receive APCM services from clinical staff under the direction of a physician or other qualified healthcare professional. Conditions must significantly increase risk of death, acute exacerbation/decompensation, or functional decline.

Reimbursement Rate: $50 (approximately)

HCPCS Code G0558

A patient who is a Qualified Medicare Beneficiary (QMB) and who has two or more high-risk chronic conditions expected to last at least 12 months (or until the death of the patient) may receive APCM services from clinical staff under the direction of a physician or other qualified healthcare professional. Conditions must significantly increase risk of death, acute exacerbation/decompensation, or functional decline.

Reimbursement Rate: $110 (approximately)

CMS Billing Requirements Updated for RHCs and FQHCs

New CMS billing requirements for rural health clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will provide updates for service reporting, telecommunication services, intensive outpatient program (IOP) services, and more.

Reporting Care Coordination Services in RHCs and FQHCs

Starting in 2025, reporting codes will change for RHCs and FQHCs. Rather than reporting the single HCPCS code G0511, they will instead report the individual CPT and HCPCS codes related to care coordination services. RHCs and FQHCs will be given a six-month period (at least until July 1, 2025) to facilitate the transition and update billing systems.

CMS is also finalizing a policy to allow billing of associated add-on codes for these services.

Coding and Policies for APCM Services

Also beginning in 2025, CMS is adopting the finalized coding and policy rules regarding RHC and FQHC payments for APCM services. Under these rules:

  • For individual codes on RHC or FQHC claims (alone or with other payments) payments would be made at national, non-facility PFS amounts.
  • These services would be paid in addition to the RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS).
  • Rates would be updated annually.

RHC Productivity Standards

CMS will remove the outdated and redundant RHC productivity standards that can impact AIR, effective for reporting periods beginning on or after January 1, 2025. Current RHC payment limits are laid out in section 130 of the CAA, 2021.

Rebasing and Revising of the FQHC Market Basket

CMS will rebase and revise the FQHC market basket to reflect more recent FQHC cost structures, including cost weights and price proxies. With 2022 as a base year, productivity adjustments will be made to the market basket percentage increase.

AMA Removes 16-Day Readings Requirement for RPM

In a game-changing move, the American Medical Association (AMA) announced that effective January 1, 2026, providers will no longer be required to furnish 16 days of patient readings per month to be reimbursed for RPM services. This decision will make it easier for providers to receive reimbursements for services provided even if patients do not take at least 16 days of readings.

Make 2025 Your Best Year Yet

As you prepare your practice for 2025, HealthXL is your go-to resource for end-to-end chronic care management and remote patient monitoring services. We would love to help you make the most of the coming year by boosting your practice revenue, improving outcomes for patients with chronic illnesses, and delivering value-based virtual care.

Ready to get started? Reach out to us today to request a call!