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Medicare | RHCs / FQHCs

How the CMS 2025 Final Rule Affects Rural Providers

January 8th, 2025 | 7 min. read

Daniel Godla

Daniel Godla

Founder and CEO of ThoroughCare

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The Centers for Medicare & Medicaid Services (CMS) released the Final Rule for its 2025 Medicare Physician Fee Schedule. It includes a significant change for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). 

As of January 1, 2025, rural providers can bill for care management services using individual HCPCS/CPT codes and add-on codes rather than the single code G0511. 

CMS allows use of individual care management codes

In 2024, G0511 was updated to cover eight care management programs and 28 HCPCS codes. G0511 was also enhanced to allow billing for multiple instances in a given month. 

However, prior to the CY 2024 Final Rule, clinicians and healthcare professionals had requested CMS give rural providers and FQHCs access to fee-for-service billing codes. 

CMS met this request in creating the CY 2025 Final Rule, which says, “We believe the non-face-to-face time required to coordinate care is not captured in the RHC AIR or the FQHC PPS payment, particularly for the rural and/or low-income populations served by RHCs and FQHCs. Allowing separate payment for CCM services in RHCs and FQHCs is intended to reflect the additional resources necessary for the unique components of CCM services.”

Giving RHCs/FQHCs access to individual billing codes (as shown below) aims to improve payment accuracy and provide clarity about which services beneficiaries receive. 

Transition period to billing care management codes

CMS is implementing a six-month transition period to enable qualified rural providers to update their billing systems and procedures. 

The transition period is currently set to end on July 1, 2025; however, it could be extended further. However, beginning January 1, 2025, RHCs and FQHCs may begin billing individual HCPCS/CPT codes if they so choose. 

Which Medicare care management programs can RHCs/FQHCs begin billing individually?

A complete list of care management programs (by launch year) and their individual HCPCS/CPT codes is below. Individual codes cover 10 care management programs and 31 services, including add-on time codes. 

To read more about each HCPCS/CPT code and its requirements, go to pages 842-849 in the CY 2025 Final Rule document. 

Medicare care management programs by launch year

Advanced Primary Care Management (2025)

  • GPCM1: Bundled care management for patients with one or no chronic illness provided by clinical staff directed by a physician or other qualified healthcare professional 
  • GPCM2: Basic elements of GPCM1 for patients with two or more chronic conditions 
  • GPCM3: Any patient who is a Qualified Medicare Beneficiary and meets the criteria for GPCM2

Principal Illness Navigation (2024)

  • G0023: 60 minutes of Principal Illness Navigation
  • G0024: 30 additional minutes of Principal Illness Navigation
  • G0140: 60 minutes of peer support time
  • G0146: 60 additional minutes of peer support time

Community Health Integration (2024)

  • G0019: 60 minutes of Community Health Integration
  • G0022: 30 additional minutes of Community Health Integration

Chronic Pain Management (2023)

  • G3002: 30 minutes of Chronic Pain Management
  • G3003: 15 additional minutes of Chronic Pain Management

Remote Therapeutic Monitoring (2022)

  • 98975: Remote Therapeutic Monitoring initial set-up and patient education on equipment use
  • 98976: Remote Therapeutic Monitoring physiological data review with at least 16 days of readings
  • 98977: 20 minutes of Remote Therapeutic Monitoring
  • 98980: 20 minutes of Remote Therapeutic Monitoring (Physician-delivered)
  • 98981: 20 additional minutes of Remote Therapeutic Monitoring (Physician-delivered)

Principal Care Management (2020)

  • 99424: 30 minutes of Principal Care Management (Physician-delivered)
  • 99425: 30 additional minutes of Principal Care Management (Physician-delivered)
  • 99426: 30 minutes of Principal Care Management (Clinician-delivered)
  • 99427: 30 additional minutes of Principal Care Management (Clinician-delivered)

Remote Patient Monitoring (2019)

  • 99453: Initial device set up and education; must capture 16 daily readings, billed once per device, each new device billed in separate months
  • 99454: Remote Patient Monitoring physiological data review with at least 16 days of readings
  • 99457: 20 minutes of Remote Patient Monitoring clinical engagement
  • 99458: 20 additional minutes of Remote Patient Monitoring clinical engagement
  • 99474: Digitally stored data services
  • 99091: Interpretation of Remote Patient Monitoring data plus 30 minutes of clinical time

Behavioral Health Integration (2017)

Advance Care Planning (2016)

  • 99497: Advance Care Planning, first 30 minutes (separately reported with an AWV only)
  • 99498: Advance Care Planning, additional 30 minutes (separately reported with an AWV only)

Chronic Care Management (2015)

  • 99490: 20 minutes of Chronic Care Management (Non-complex)
  • 99439: 20 additional minutes of Chronic Care Management (Non-complex)
  • 99487: 60 minutes of Chronic Care Management (Complex)
  • 99489: 30 additional minutes of Chronic Care Management (Complex)
  • 99491: 30 minutes of Chronic Care Management (Physician-delivered)
  • 99437: 30 additional minutes of Chronic Care Management (Physician-delivered)

Annual Wellness Visit (2011)

  • G0402: "Welcome to Medicare" visit (IPPE)
  • G0438: Initial Annual Wellness Visit (AWV)
  • G0439: Subsequent AWV
  • G0101: Pelvic and breast exam
  • G0102: Prostate cancer screening: digital rectal examination
  • G0403: Electrocardiogram, with interpretation and report (separately reported with an IPPE only)
  • G0442: Alcohol misuse screening (separately reported with an AWV only)
  • G0443: Face-to-face behavioral counseling for alcohol misuse, 15 minutes (maximum of four per year, separately reported with an AWV only)
  • 60444: Depression screening (separately reported with a subsequent AWV only)
  • G0445: High-intensity behavioral counseling to prevent STIs, performed semi-annually, 30 minutes
  • G0446: Intensive behavioral counseling for cardiovascular disease, 15 minutes
  • G0447: Face-to-face behavioral counseling for obesity (BMI greater than 30), 15 minutes 
  • 99406: Tobacco use counseling, three to 10 minutes (maximum of eight per year if combined with 99407)
  • 99407: Tobacco use counseling, more than 10 minutes (maximum of four per year)

ThoroughCare streamlines reimbursement

ThoroughCare helps RHCs and FQHCs adapt their operations to maximize the value of care management. Our comprehensive software platform supports end-to-end workflow and simplified billing for Medicare programs.

ThoroughCare provides a structured approach to: 

  • Enrolling patients in care management programs
  • Creating and maintaining care plans while educating patients on self-care
  • Communicating with patients through secure two-way texting
  • Tracking and reporting on program requirements with data analytics
  • Automating device- and time-based claims documentation for auditing

Incorporating the latest Medicare rules and rates, ThoroughCare facilitates evidence-based standards, seamless workflows, and features that simplify compliant billing.

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Key questions answered

How will Medicare care management billing change for RHCs and FQHCs in 2025?

The 2025 Medicare Physician Fee Schedule includes a significant change for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). 

Starting January 1, 2025, these rural providers may bill for care management services using individual HCPCS/CPT codes and add-on codes rather than the single code G0511. 

When will Rural Health Clinics and Federally Qualified Health Centers need to stop billing code G0511 and start billing individual care management HCPCS and CPT codes?

According to the CY Final Rule, RHCs and FQHCs may begin billing individual HCPCS/CPT codes on January 1, 2025. 

The transition period for RHCs and FQHCs to stop using G0511 and begin using individual HCPCS/CPT codes is currently set to end July 1, 2025; however, it could be extended further.