The Centers for Medicare & Medicaid Services (CMS) has released the Final Rule for its 2025 Medicare Physician Fee Schedule. According to a CMS fact sheet, this update continues efforts to strengthen primary care, support preventive care, and promote better access to behavioral health.
The 2025 Final Rule offers opportunities for providers to make up for the decrease in conversion rates. For instance, new care management programs, such as Advanced Primary Care Management, could maximize team-based strategies for improved outcomes.
This year’s rule also offers billing changes that could make Chronic Care Management more attractive to Rural Health Clinics and Federally Qualified Health Centers.
Key updates, changes, and new programs
Below, we’ve summarized impactful changes relative to care management and new programs from the CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule.
2025 physician payment reductions
The average payment rates under the Physician Fee Schedule will be reduced by 2.93% in 2025, with an additional 0.02% adjustment in relative value units (RVUs) for some services. The conversion factor—the amount Medicare pays per RVU—will see an overall 2.83% reduction to $32.35.
Similar to the mid-year increase in the conversion factor after the CY2024 Final Rule was implemented, it’s possible that Congress could pass the Medicare Patient Access and Practice Stabilization Act. This would eliminate the conversion factor cut and provide a modest (possibly 1.8%) inflation increase. In the wake of the Presidential election and changes to Congress, it remains to be seen if the 2025 budget would allow these adjustments.
Advanced Primary Care Management (APCM)
The Advanced Primary Care Management program will be billable under three new HCPCS G-codes and incorporate elements of existing care management services, such as Principal Care Management, Chronic Care Management, and Transitional Care Management.
The three new codes vary in reimbursement rates based on the number of chronic conditions and QMB status:
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
A QMB is a Medicare beneficiary who receives assistance from their state to pay for Medicare costs. They are not legally required to pay for Medicare cost-sharing, including deductibles, co-insurance, and copays.
APCM delivers care management services via communication-based technologies without any time-based thresholds. The three levels of the program offer a monthly payment for providing all primary care and serving as the coordinator for any needed services.
Required elements include:
- Patient consent – which can be verbal
- An initiating visit – if they haven’t been under care for three years or more
- 24/7 access and continuity of care
- Comprehensive care management
- A patient-centered comprehensive care plan
- Care transition management
- Care coordination
- Enhanced communication
- Population-level management
- Performance measurement
While the program focuses on primary care specialties, other specialists overseeing primary care for complex patients may participate if they act as the central coordination point for all needed care.
APCM aims to streamline billing and reimbursement for primary care services with hybrid payments. This includes a mix of encounter and population-based payments for longitudinal care.
Unbundling G0511 for RHCs and FQHCs
The CY 2025 Final Rule includes a significant change for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Starting January 1, 2025, rural providers can bill for care management services using individual HCPCS codes and add-on codes rather than the single code G0511.
This change aims to improve payment accuracy and provide greater clarity about which specific services beneficiaries are receiving.
Most recently, G0511 covered eight different care management programs and 28 HCPCS codes and was updated to allow billing for multiple instances in a given month.
CMS is implementing a six-month or longer transition period to enable qualified rural providers to update their billing systems and procedures. Providers can also immediately bill individual CPT codes if they so choose.
RHCs and FQHCs will also be able to access the new Advanced Primary Care Management through payments at the national non-facility rates.
Other important changes in the CY2025 Final Rule
In addition to these two program and coding updates, the following additions and expansions provide service and revenue opportunities across a myriad of care priorities.
Caregiver Training Services (CTS)
The Final Rule establishes coding and payment for caregiver training for direct care services.
Training can be provided by the following roles when delivered personally or by practitioners or auxiliary personnel under the billing clinician’s supervision:
- Physicians
- Nurse practitioners (NPs)
- Clinical nurse specialists (CNSs)
- Certified nurse-midwives (CNMs)
- Physician assistants (PAs)
- Clinical psychologists (CPs)
Training topics can be wide-ranging but must focus on clinical caregiver skills related to hands-on treatment, reducing complications, or monitoring the patient. Examples of topics that directly support the patient’s treatment plan could include techniques to prevent decubitus ulcer formation, wound care, and infection control.
There are three new HCPCS codes that cover CTS, including:
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Under HCPCS code 96161, providers can also conduct a caregiver assessment when reasonable and necessary. The evaluation assesses the caregiver’s skills and knowledge for the purpose of caregiver training.
CTS guidelines indicate that the patient must consent for their caregiver to receive training or the assessment. The patient does not need to be present for either service.
CMS also established two other HCPCS codes for face-to-face caregiver training in behavior management for patients with a mental or physical health diagnosis. The two codes include:
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Cardiovascular Risk Assessment and Management
The Final Rule establishes the Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment and management program. When a practitioner identifies a patient at risk for cardiovascular disease but who does not have a diagnosis of CVD, this service can be performed in conjunction with an evaluation and management (E/M) visit.
The evidence-based risk assessment tool uses the following data to create a 10-year risk score:
- Demographic data (e.g., age, sex)
- Modifiable risk factors for CVD (e.g., blood pressure & cholesterol control, smoking status/history, alcohol and other drug use, physical activity and nutrition, obesity)
- Possible risk enhancers (e.g., pre-eclampsia)
- Laboratory data (lipid panel)
The new program provides HCPCS codes and payment for ASCVD risk management services, including care options such as aspirin, blood pressure management, cholesterol management, and smoking cessation.
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Behavioral Health Safety Planning Interventions
New coding covers safety planning for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose.
This includes an add-on G-code billable with E/M visits or psychotherapy with a monthly billing code for post-discharge follow-up. The G-code may be billed in 20-minute increments. It can be for safety planning interventions that the billing practitioner personally performs in various settings.
The monthly billing code covers bundled services for post-discharge follow-up. It’s in conjunction with a discharge from the emergency department for a crisis encounter.
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Digital Mental Health Treatment
Three new HCPCS codes cover digital mental health treatment services and devices.
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Devices must be cleared under section 510(k) of the Federal Food, Drug and Cosmetic Act or granted authorization by FDA and classified under 21 CFR 882.580.
The Final Rule also creates six G codes for practitioners in specialties whose covered services are limited by statute for diagnosing and treating mental illness. These practitioners include:
- Clinical psychologists
- Clinical social workers
- Marriage and family therapists
- Mental health counselors
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.
Evaluation & Management add-on complexity code refinement
CMS announced a refinement to the add-on code G2211 initiated in CY 2024. It must be used in conjunction with the Office/Outpatient (O/O) Evaluation and Management (E/M) Visit base HCPCS codes 99202-99205 and 99211-99215. Now, G2211 should be documented by a single practitioner on the day of an Annual Wellness Visit, vaccine administration, or any Medicare Part B preventive service.
The Final Rule states that the new code's purpose is to reflect the time, intensity, and resources “involved when practitioners furnish the kinds of O/O E/M visit services that enable them to build longitudinal relationships with all patients.”
In 2024, G2211 was reimbursed at a national rate of $16.31. Based on an RVU of 0.49 and a reduced conversion rate, G2211 would be paid at $15.85*.
ThoroughCare is your technology partner for 2025
ThoroughCare prepares your team for 2025 with intuitive digital tools and care coordination training that supports better care and expands revenue streams.
Encompassing the latest Medicare rules and rates, ThoroughCare enables fee-for-service programs through evidence-based standards, seamless workflows, and features to make compliant billing easy.
With one platform, all of these care management programs are ready to be turned on simply by enrolling a patient:
- Principal Care Management (1 condition)
- Chronic Care Management (2 or more conditions)
- Remote Patient Monitoring (standalone or combined with other programs)
- Transitional Care Management (30-day program)
- Behavioral Health Integration
- Annual Wellness Visits
Along with software, ThoroughCare provides clinical consulting services to empower teams with expert guidance and training in care coordination. Our clinicians and care managers help you develop programs and optimize workflow.
*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.