By Juli Eschenbach, Custom Solutions Manager and Clinical SME

The 2025 physician fee schedule (PFS) that went into effect January 1 from the Centers for Medicare & Medicaid Services (CMS) strongly supports existing billing, coding, and delivery of remote patient monitoring (RPM) and chronic care management (CCM).

But there are myriad PFS additions and enhancements, notably around major billing changes for federally qualified healthcare centers (FQHCs), and the introduction of advanced primary care management (APCM). The latter is an amalgamation of existing Medicare care management programs, like CCM and Principal Care Management, but with one specific difference that signals a cultural sea change: the lack of time-based thresholds.

Takeaway #1: Medicare presses the gas on value-based care

In a traditional fee-for-service payment model, providers are incentivized to stick within the boundaries of what are typically 20-minute (CCM) or 30-minute (PCM) increments. In the “simplest” CCM instance managing as few as two chronic conditions, 20 minutes of non-visit clinical staff time must be spent and documented on CCM qualifying activities per calendar month to qualify for the first payment unit.  The same process is also completed for the 40- and 60-minute time thresholds for qualifying CCM activity. APCM is a symbolic nod to Medicare’s greater push toward value-based care and compensating for outcomes over volume or quantitative measures.

This qualitative movement into value-based care has progressed in recent years, according to years of data from the CMS Innovation Center. CMS data show that VBC models saw a 25% increase in health care provider participation from 2023 to 2024, and nearly 70 percent of Medicare Advantage enrollees opted for VBC providers in 2022. When patients and their providers agree on value-based approach to care and payment for said care, the entire system only stands to benefit.

Takeaway #2: CCM, RPM, and PCM aren’t going anywhere

APCM is a new kid on the block – not a replacement for chronic care management, remote patient management, or principal care management.

One of the biggest differences comparing APCM to the other models is the risk stratification model into three levels. Under CCM, patients must have two or more chronic conditions such as arthritis, asthma, cancer, diabetes, or heart disease and meet time thresholds of giving care outside a visit. APCM codes remove this time requirement, instead basing care on a for valuation of care model.   These new codes have the potential to make nearly all consented Medicare patients billable each month even if they have one or fewer chronic conditions. The less complicated the patient, the less the primary care provider gets compensated (especially compared to potential CCM rates) but APCM providers are still compensated as long as they participate in a value-based care program (like MIPS).

Although APCM can be billed for patients who are treated for less than 20 minutes, there is a comprehensive list of other service elements to consider in order support the new program. This includes elements such as technology-supported bidirectional communication (other than telephone, which is not considered technology by CMS) between patients and providers; 24/7 access to care; continuity of care, a care plan that must be electronically available and shared with the patient or their caregiver, and population data and risk stratification data.

With frameworks requiring digital engagement, it’s essential to invest resources in technology that makes that engagement as seamless as possible for both providers and their patients.

Takeaway #3: Major billing changes for FQHC/RHCs

Starting in 2025, there will be a sunsetting of the flat-rate code (G0511) for all care management services covered by FQHC/RHCs, under the CMS stipulation that it is “important to identify the actual services being furnished.” The change essentially allows federally qualified healthcare centers and rural health clinics to bill like independent physician practices, using the for-fee-service codes for each qualifying billing instead of multiple instances of G0511 for any type of care management. There’s more transparency in billing, proper payment for care services rendered, and the allowance of “add-on codes” (existing care management CPT codes).

The unbundling of the previous flat-rate code pays less per instance but should encourage FQHCs and RHCs to focus on the full suite of care management services like CCM, RPM, PCM, BHI, and even the new APCM. The previous coding incentivized providers to keep care management services to 20 minutes or less per care activity – but patients in such settings often need more care management time. Transitioning to the expanded set of for fee service CPT codes for these care management services increases potential revenue in many cases, and increases the likelihood that patients will receive the services they need.