The 2025 Physician Fee Schedule (PFS) Final Rule represents a significant shift for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). By unbundling key billing codes, introducing Advanced Primary Care Management (APCM) services, and refining telehealth policies, CMS enables these facilities to modernize care delivery, improve patient outcomes, and streamline billing practices.
The rule is designed to align care management services with Medicare’s evolving payment frameworks while supporting underserved communities with advanced remote patient monitoring (RPM) technologies.
Key Updates: Breaking Down the Changes
- Unbundling of G0511 for Precision in Billing
A major update in the 2025 PFS Final Rule is the unbundling of HCPCS code G0511. This code previously encompassed multiple care management services, including chronic care management (CCM), remote patient monitoring (RPM), and remote therapeutic monitoring (RTM). Starting in 2025, CMS mandates that FQHCs and RHCs use individual CPT and HCPCS codes to bill for these services:“We are finalizing with a modification that starting in 2025, RHCs and FQHCs will report the individual CPT and HCPCS that describe care coordination services instead of the single HCPCS code G0511” (2025 Final Rule, Section III.B.2).
This change allows for greater precision in documenting care, encouraging providers to allocate more time for personalized services without being limited by the 20-minute restriction under G0511.
- Realignment with Non-Facility Payment Rates
The 2025 Final Rule realigns payments for FQHCs and RHCs to reflect the national non-facility Medicare payment rate:“For CCM, general BHI, PCM, CPM, RPM, RTM, CHI, PIN, PIN – Peer Support, and Advance Primary Care Management services furnished on or after January 1, 2025, payment is based on the PFS national non-facility payment rate.” (Section 405.2464(c)
For instance, under the 2024 rules, providers were reimbursed approximately $146 per patient per month for RPM and CCM. With the new framework, facilities offering high-complexity care can receive up to $202 per patient per month, reflecting the true intensity and complexity of the services provided.
Advanced Primary Care Management (APCM) Codes
The Advanced Primary Care Management (APCM) codes introduced in the 2025 PFS Final Rule simplify care management by bundling multiple elements, such as:
- Comprehensive patient assessments.
- Personalized care planning.
- Non-visit-based coordination.
- Documentation through advanced technology systems.
The codes include:
HCPCS Code G0556
“Advanced primary care management services for a patient with one chronic condition [expected to last at least 12 months, or until the death of the patient], which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.” (2025 Final Rule, Page 421)
Simply put: This code is designed for patients managing a single chronic condition. It emphasizes proactive care coordination by clinical staff under the supervision of a qualified provider, ensuring a focused approach to prevent deterioration and improve patient outcomes.
HCPCS Code G0557
“Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.” (2025 Final Rule, Page 400)
Simply put: This code applies to patients with two or more chronic conditions, requiring comprehensive care to manage multiple health challenges. It enables providers to deliver holistic care and coordinate all services effectively over time.
HCPCS Code G0558
“Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.” (2025 Final Rule, Page 435)
Simply put: This code is specific to high-complexity patients who are Qualified Medicare Beneficiaries (QMBs) with multiple chronic conditions. It supports advanced care planning and management tailored to the unique needs of these high-risk patients.
- G0556: For patients with one chronic condition.
- G0557: For patients with multiple chronic conditions.
- G0558: For high-complexity patients with Qualified Medicare Beneficiary (QMB) status and multiple chronic conditions.
By integrating APCM services into care workflows, FQHCs and RHCs can improve operational efficiency and patient outcomes while aligning with CMS’s emphasis on value-based care.
Telehealth and RPM: Expanded Opportunities
The 2025 PFS Final Rule underscores the growing role of telehealth in expanding healthcare access, particularly for rural and underserved populations. CMS allows for the inclusion of audio-only telehealth services under specific conditions:
“Interactive telecommunications system may also include two-way, real-time audio-only communication technology for any telehealth service furnished to a patient in their home” (2025 Final Rule, § 410.78).
Additionally, FQHCs and RHCs can continue to use HCPCS code G2025 to bill for telehealth services through December 31, 2025, ensuring uninterrupted access to remote care while adapting to the updated framework.
How DrKumo Supports Compliance with the 2025 PFS Final Rule
Innovative digital health platforms like DrKumo digital health solution uses RPM technology and integrates real-time patient monitoring with billing support tools, helping providers align with CMS’s updated policies.
- Real-Time Monitoring: Collects and organizes physiologic data, such as blood pressure and oxygen levels, providing valuable insights to support accurate documentation and billing processes.
- Telehealth Integration: Supports audio and video communication to meet CMS’s expanded telehealth requirements.
- Streamlined Reporting: Generates actionable billing reports, ensuring alignment with the unbundled CPT and HCPCS codes.
Preparing for the Transition: Action Steps for Providers
CMS has provided a six-month compliance period to facilitate the transition to the new billing framework:
“We are also allowing RHCs and FQHCs to come into compliance by at least until July 1, 2025, to enable those RHCs and FQHCs to be able to update their billing systems” (2025 Final Rule, Section III.B.2).
FQHCs and RHCs should:
- Update Billing Systems: Ensure compatibility with individual CPT and HCPCS codes.
- Train Staff: Educate administrative and clinical teams on APCM workflows and telehealth documentation.
- Invest in Technology: Adopt RPM platforms like DrKumo to streamline operations and ensure compliance.
Takeaways
The 2025 PFS Final Rule empowers FQHCs and RHCs to embrace a more precise, value-based care delivery model. By unbundling G0511, introducing APCM codes, and expanding telehealth capabilities, The updated CMS framework enables healthcare providers to adopt tools and strategies that enhance patient outcomes and maximize reimbursements.
As the healthcare landscape evolves, leaders in digital health solutions like DrKumo offer the technological foundation needed to navigate these changes confidently. By combining real-time monitoring, advanced billing tools, and compliance-driven features with effective workflows, FQHCs and RHCs can modernize chronic care management while meeting the requirements of the 2025 Final Rule.
Are you ready to align with the future of care delivery? Discover how DrKumo’s RPM solutions can streamline your billing practices and optimize patient care under the 2025 PFS Final Rule. Contact us today to elevate your care delivery model and ensure compliance with CMS guidelines.
