The Centers for Medicare and Medicaid Services (CMS) proposed a rule on July 10, 2024 that would change how federally qualified health centers (FQHCs) and rural health clinics (RHCs) are reimbursed for care management services in 2025. The rule would remove the current code G0511, which is used for remote therapeutic monitoring (RPM) and care management services (CCM), and instead have FQHCs and RHCs bill each care coordination service individually using the same codes that traditional ambulatory practices use. For example, the most common CCM code, CPT 99490, would be used. Payment would be at the national non-facility MPFS payment rate.
The RPM CMS 2025 Proposed Rule Introduces Changes to CCM Services
New Advanced Primary Care Management (APCM) Codes
The CMS 2025 Proposed Rule introduces several significant changes related to Chronic Care Management (CCM) services:
New Advanced Primary Care Management (APCM) Codes
CMS is proposing to establish new HCPCS G-codes for Advanced Primary Care Management (APCM) services[1][3]. These new codes would combine elements from several existing care management services, including Chronic Care Management, into comprehensive bundles:
– The APCM codes (GPCM1, GPCM2, GPCM3) would bundle CCM with Principal Care Management, transitional care management, and certain communication technology-based services[3].
– Unlike current CCM codes, the new APCM codes would not be time-based, allowing billing for care management that doesn’t meet the current 20 or 30-minute thresholds[3].
Changes for FQHCs and RHCs for RPM CMS
For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), CMS proposes to:
– Remove the current G0511 code used for CCM and other services[1][3].
– Allow FQHCs and RHCs to use existing care management CPT codes, including the proposed APCM codes if finalized[1].
– Reimburse these services at the national non-facility Medicare Physician Fee Schedule payment rate[1].
Focus on Comprehensive Care under RPM CMS
The proposed changes aim to shift focus from time-based activities to providing more comprehensive and accessible care management services[3]. This aligns with lessons learned from CMS Innovation Center’s advanced primary care demonstration models.
These proposals represent a significant restructuring of how chronic care management services are coded and reimbursed, potentially offering more flexibility in care delivery while bundling various care management activities into more comprehensive service packages.
TEXT FROM 2025 RPM CMS PROPOSED RULE
Advanced Primary Care Management Services (APCM)
A strong foundational primary care system is fundamental to improving health outcomes, lowering mortality, and reducing health disparities, which is why the Department of Health and Human Services has been taking action to strengthen primary care, starting with payment for advanced primary care management services.
For CY 2025, we are proposing to establish coding and make payment under the PFS for a new set of APCM services described by three new HCPCS G-codes. The proposed APCM services would incorporate elements of several existing care management and communication technology-based services into a bundle of services that reflects the essential elements of the delivery of advanced primary care, including Principal Care Management, Transitional Care Management, and Chronic Care Management. The new APCM codes would be stratified into three levels based on the number of chronic conditions and enrollment as a Qualified Medicare Beneficiary, reflecting both patient medical and social complexity. This new proposed coding and payment makes use of lessons learned from the CMS Innovation Center’s testing of a series of advanced primary care models, such as Comprehensive Primary Care Plus (CPC+) and Primary Care First (PCF), to inform the elements of APCM services and is intended to reduce the administrative burden associated with current coding and billing rules.
We are proposing that beginning January 1, 2025, physicians and non-physician practitioners (NPPs) who use an advanced primary care model of care delivery could bill for APCM services when they are the continuing focal point for all needed health care services and responsible for all the patient’s primary care services, as described in the proposed service elements of the codes. In addition, we are proposing as a condition of payment for APCM services a performance measurement requirement, which can be satisfied by reporting the Value in Primary Care MIPS Value Pathway (MVP), as it was developed to include quality measures that reflect clinical actions that should be considered the foundation of primary care, and holds practitioners accountable for the total cost and quality of the care they provide. Reporting for the MVP would begin in 2026 based on the 2025 performance year.
This new coding and payment would better recognize and describe advanced primary care services, encourage primary care practice transformation, help ensure that patients have access to high quality primary care services, and simplify billing and documentation requirements, as compared to existing care management and communication technology-based services codes. The proposed codes also represent a step towards paying for primary care services with hybrid payments (a mix of encounter and population-based payments) to support longitudinal relationships between primary care providers and beneficiaries by paying for care in larger units of service, and also help drive accountable care. Physicians and NPPs in Shared Savings Program ACOs, and some Innovation Center models satisfy requirements for these codes.
We are seeking comment from interested parties through an Advanced Primary Care Hybrid Payment RFI on whether and how we should consider additional payment policies that recognize the delivery of advanced primary care services.
Behavioral Health Services
In this rule, CMS is proposing several additional actions to help support access to behavioral health, in line with the CMS Behavioral Health Strategy.
Several studies have demonstrated that safety planning, when properly performed, can help prevent suicide. For CY 2025, we are proposing to establish separate coding and payment under the PFS describing safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose. Specifically, we are proposing to create an add-on G-code that would be billed along with an E/M visit or psychotherapy service when safety planning interventions are personally performed by the billing practitioner in a variety of settings. Additionally, we are proposing to create a monthly billing code to that requires specific protocols in furnishing post-discharge follow-up contacts that are performed in conjunction with a discharge from the emergency department for a crisis encounter, as a bundled service describing four calls in a month.
To further support access to psychotherapy, we are also proposing Medicare payment for digital mental health treatment devices furnished incident to or integral to professional behavioral health services used in conjunction with ongoing behavioral health care treatment under a behavioral health treatment plan of care. We are proposing to create three new HCPCS codes and we would monitor how digital mental health treatment devices are used as part of overall behavioral health care. We are also proposing to create six G codes to be billed by practitioners in specialties whose covered services are limited by statute to services for the diagnosis and treatment of mental illness (including Clinical Psychologists, Clinical Social Workers, Marriage and Family Therapists, and Mental Health Counselors) to mirror current interprofessional consultation CPT codes used by practitioners who are eligible to bill E/M visits. If finalized, this would allow for better integration of behavioral health specialty treatment into primary care and other settings.
Founder at RPM Logix – Remote Personalized Medicine