The care management code updates in the 2025 Final Physician Fee Schedule from Centers for Medicare & Medicaid Services (CMS) could have far-reaching implications for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Organizations serving underserved areas are expected to benefit from the changes, which introduce enhanced reimbursement structures that will enable them to elevate patient services and accelerate their transition to value-based care models. Among the key changes are updates to the Healthcare Common Procedure Coding System (HCPCS) code G0511 and the introduction of the Advanced Primary Care Management (APCM) code. These changes represent a pivotal opportunity for RHCs and FQHCs to improve outcomes, make programs more sustainable, and align more closely with modern care initiatives.
One of the most impactful updates involves the January 2025 elimination of the general code G0511. The full transition period will last six months and, by July 2025, RHCs and FQHCs must be using specific CPT and HCPCS codes – such as CPT 99490 for non-complex Chronic Care Management (CCM) and CPT 99457 for Remote Patient Monitoring services – rather than using G0511 each time a service under the general care management umbrella is completed. The change from CMS ensures reimbursement reflects the full scope and complexity of extended care management activities.
This change marks a move toward increased clarity and precision in reimbursement, ensuring that payments are aligned with the specific services delivered. By transitioning from the blanket G0511 code to individual codes, the new approach allows for more accurate and fair reimbursement for RPM services. It will also allow rural clinics and community health centers more financial flexibility to implement creative solutions addressing their specific challenges, such as staffing shortages and geographic limitations.
The shift exemplifies CMS’s focus on enhancing financial sustainability and improving healthcare delivery in underserved areas. During the next six months leading up to the July 2025 deadline, FQHCs and RHCs are encouraged to update billing systems, train staff on the new coding requirements, and integrate these changes into their workflows. Here are the key things to know throughout the transition.
Advanced Primary Care Management Codes Furthers Shift Toward Value-Based Care
The introduction of APCM services for all Medicare beneficiaries further expands billing opportunities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), which are eligible to bill for these services using new HCPCS codes. APCM prioritizes holistic care and whole-person wellness by integrating three established care management programs: Principal Care Management (PCM), Transitional Care Management (TCM), and Chronic Care Management (CCM). While APCM cannot be billed concurrently with CCM for the same patient in the same month, RHCs and FQHCs can bill APCM alongside RPM or other complementary services. CMS has introduced three new HCPCS codes for APCM services:
- G0556 for patients with one chronic condition
- G0557 for individuals with two or more chronic conditions
- G0558 for patients with two or more chronic conditions and are Qualified Medicare Beneficiaries (QMBs)
Unlike traditional time-based care management codes, APCM codes eliminate specific time requirements. The reduced administrative burden allows healthcare providers to focus more on patients rather than how much time is spent on assorted services.
The APCM marks a major shift from paying for care based on time to paying for results. This new approach focuses on identifying high-risk patients, using team-based care, and tracking performance, which enables FQHCs and RHCs to deliver more effective, patient-centered support. Facilities participating in existing CMS initiatives, such as the Medicare Shared Savings Program and Making Care Primary, will automatically meet some APCM requirements, facilitating alignment between new and legacy programs.
Rural Providers Face Opportunities and Challenges with Enhanced Reimbursement
With the new APCM codes FQHCs and RHCs gain access to enhanced reimbursement tailored to three levels of patient complexity. This move acknowledges the varying needs of their diverse patient populations and provides the financial resources necessary to deliver high-quality care. The updated care management codes and new APCM model open numerous possibilities, such as:
- Improved Patient Care: Tailored reimbursement structures empower clinics to provide more comprehensive care coordination services to address complex needs.
- Value-Based Care Shift: The emphasis on outcomes strengthens the foundation for sustainable, value-based healthcare delivery.
- Community Health Initiatives: Enhanced financial sustainability enables investment in programs that address broader social determinants of health in underserved areas.
- Better Recruitment and Retention: Competitive reimbursement models can improve staff recruitment and retention, a long-standing challenge for rural facilities.
- Flexibility with Outsourced Clinical Staff: RPM, RTM, CCM, and APCM can be billed under the general supervision of a billing provider, meaning third-party auxiliary clinical staff can support these programs.
- Sustainability for RPM, RTM, and CCM Programs: Facilities can allocate resources toward innovative programs that improve both care delivery and patient engagement while reducing hospital readmissions.
The updates offer transformative possibilities for safety-net providers. As they navigate the six-month transition period and look to maximize the new regulations’ benefits, it will be important to proactively address:
- Training Requirements: Staff at RHCs and FQHCs may need education on new coding practices, APCM protocols, and documentation requirements.
- Digital Updates: Implementing new billing codes might necessitate updates to IT infrastructure.
- Operational Adjustments: Adding RPM, CCM or APCM requires advanced planning to ensure efficient workflows and resource allocation.
- Navigating the Learning Curve: As FQHCs and RHCs temporarily dedicate resources to understanding and executing these updates, they might want to make operational adjustments.
The recent updates to care management codes for RHCs and FQHCs, coupled with the introduction of APCM, represent a historic opportunity for rural and community healthcare providers. By transitioning to more transparent and equitable reimbursement structures and beginning to emphasize outcomes over time-based measures, CMS has laid the groundwork for enhanced patient care, improved operational efficiency, and increased financial sustainability.
To fully capitalize on these changes, however, leaders within RHCs and FQHCs must proactively address training, system upgrades, and operational challenges. With strategic planning and a progressive approach, these updates can transform patient outcomes in underserved areas, bringing healthcare delivery closer to the goal of equitable, value-based care.
For healthcare administrators and clinic leaders, this is a pivotal moment. Navigating these updates effectively may improve their facilities’ financial sustainability and organizational resilience while upholding the mission to serve vulnerable populations. These changes could propel rural healthcare into a new era of delivery and community benefits.
About Lucienne Marie Ide, M.D., PH.D.
Lucienne Marie Ide, M.D., PH.D., is the founder and Chief Executive Officer of Rimidi, a digital health company that supports healthcare providers in the delivery of remote patient monitoring and chronic disease management with EHR-integrated software, services, and connected devices. She brings her diverse experiences in medicine, science, venture capital, and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry, and society, after completing her internship in Obstetrics and Gynecology at UPMC, Dr. Ide left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize an industry.
