Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) play a critical role in delivering healthcare to millions of Americans across the United States. Each year, updates to Medicare’s Physician Fee Schedule (MPFS) directly affect the reimbursements these Community Health Centers (CHCs) receive, impacting their financial stability and service delivery.
The 2025 Final Rule introduces pivotal changes that reshape the reimbursement framework for Care Management Services in CHCs that will affect how CHCs are reimbursed for Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and other Care Coordination Services. The updates will enhance reimbursement rates and have a significant impact on patients’ access to these essential services.
Key Changes
Starting July 1, 2025, the Final Rule will create a more equitable Medicare reimbursement system for Community Health Centers, leveling the playing field between CHCs and traditional practices. The existing HCPCP G0511 code will be eliminated and for the first time, Federally FQHCs and RHCs will be able to bill for each care management service individually, including the associated add-on codes.
Clarity Around HCPCS Code G0511 and New Coding
While traditional providers have long had separate codes for billing various care management services, CHCs were initially excluded from this practice. The G0511 code was created as a way for CHCs to bill Medicare for various care management services, separate from their Prospective Payment System (PPS) rate. Over time, numerous care management services, each with individual billing codes, were consolidated under this single code for CHCs. By eliminating the bundled G0511 code and allowing CHCs to bill using the same codes as traditional providers, FQHCs and RHCs will gain more accurate reimbursement. This change ensures their payment aligns with the care and time provided, adequately compensating for distinct services like Chronic Care Management and Remote Patient Monitoring.
For example, under the current system, the maximum reimbursement for Remote Patient Monitoring services is $73, regardless of the clinical time spent beyond 20 minutes. However, as of January 1, 2025, Medicare’s maximum reimbursement for RPM will increase to up to $179 per patient per month. This adjustment is designed to help FQHCs cover operational costs, expand their services, and better support patients with chronic conditions, representing a significant win for FQHCs and RHCs.
Summary of RPM and CCM Reimbursement Changes
Remote Patient Monitoring
Enables healthcare providers to monitor patients’ health data in real time, reducing hospital readmissions and emergency room visits by catching potential health issues early. Remote health monitoring is particularly effective in managing chronic diseases like diabetes, hypertension, and heart disease.
Most Commonly utilized RPM codes include:
- 99453: Initial set-up and patient training on the use of equipment
- 99454: The provider supplies the patient with remote physiologic monitoring equipment and receives daily recordings and/or programmed alerts. 16 days of device utilization required
- 99457: Monitoring a patient’s remote physiologic recordings and/or programmed alerts and interaction with the patient. First 20 mins of time.
- 99458: (add-on code) additional 20-minute increments of clinical time.
Chronic Care Management
Service aimed at supporting patients with two or more chronic conditions. It involves the development and monthly review of a coordinated care plan in collaboration with the patient, focusing on managing their care at home and between office visits. For CHCs which often serve older adults and individuals with various chronic conditions, CCM can significantly reduce hospital readmissions and improve patient outcomes by providing proactive care that enhances patient well-being and reduces strain on the healthcare system.
Most Commonly Used CCM Billing Codes:
- 99490: Clinical staff provides 20 minutes of care planning and coordination.
- 99439: (add-on code) additional increments of 20 mins of time spent with patient on care planning and coordination.
Summary of Rate Changes for RPM and CCM
Note: These figures reflect the maximum reimbursement potential based on Medicare national average rates, assuming optimal patient utilization and clinical time rendered.
Medicaid Reimbursements
Significant progress is underway in various states regarding Medicaid reimbursements. With the upcoming 2025 updates to the Medicare Physician Fee Schedule, combined with evidence demonstrating cost savings for Medicare through reduced overall utilization and improved patient care, it is expected that more state Medicaid programs will align their reimbursement policies to support these services
Looking Ahead
The 2025 updates to care management reimbursement mark a transformative shift for Federally Qualified Health Centers and Rural Health Clinics. By allowing CHCs to bill for individual care management services rather than relying on bundled codes, the changes will not only improve financial sustainability but also enhance their ability to provide personalized, proactive care to underserved communities.
These new reimbursement policies empower FQHCs and RHCs to invest in staff, technology, and programs that support chronic disease management and remote patient monitoring. This shift ultimately ensures better outcomes for patients while strengthening the healthcare system’s capacity to address the needs of vulnerable populations. For these clinics and their patients, 2025 promises to be a year of opportunity and progress.
To learn more about these changes, contact RemetricHealth today
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