A Comprehensive Overview for Health Systems
The 2025 Medicare Physician Fee Schedule (MPFS) Final Rule, released on November 1, 2024, introduces several significant changes aimed at advancing virtual care management (VCM) and enhancing primary care for Medicare beneficiaries. The Centers for Medicare & Medicaid Services (CMS) forward-thinking approach to enhancing care for Medicare beneficiaries and aligning payments with quality outcomes is a welcomed advancement toward delivering valuable care for our nation’s Seniors. At TimeDoc Health, we are committed to keeping our partners and clients informed about these impactful updates to support seamless adaptation and continued high-quality care delivery.
Key Highlights from the 2025 MPFS Final Rule
1. Introduction of Advanced Primary Care Management (APCM) Services
Effective January 1, 2025, CMS will implement Advanced Primary Care Management (APCM), a new payment model designed to provide comprehensive, patient-centered primary care, particularly for those managing chronic conditions. APCM expands on traditional Chronic Care Management (CCM) by introducing structured service requirements and fostering more proactive and integrated care for patients with complex healthcare needs.
Why CMS Introduced APCM
The goal behind APCM is to strengthen primary care infrastructure, improve patient outcomes, and reduce health disparities and mortality. CMS recognized that many patients, especially those with multiple chronic conditions, benefit from continuous, non-face-to-face care management that goes beyond the limits of traditional CCM. By removing time-based thresholds and simplifying billing, APCM aims to reduce the administrative burden on providers while compensating them for a wider range of care activities.
How APCM Differs from Traditional CCM
- Expanded Care Management: Requires more intensive coordination that includes medical and social care needs, surpassing the time-focused documentation of CCM.
- Structured Population Health Management: Involves tracking patient outcomes using data analysis, facilitating a proactive approach to health management.
- Comprehensive Care Plans: Practices must create and continuously update electronic, patient-centered care plans to reflect changes in patient health.
- Enhanced Care Integration: APCM necessitates greater collaboration across care teams to ensure consistent, high-quality patient care.
New APCM Codes
CMS has introduced three specific APCM billing codes:
- G0556: For patients with one or fewer chronic conditions, reimbursed at $15/month.
- G0557: For patients with two or more chronic conditions, reimbursed at $50/month.
- G0558: For Qualified Medicare Beneficiaries (QMBs) with complex needs, reimbursed at $110/month.
APCM Service Requirements
The CMS Final Rule specifies that APCM services shall be provided by clinical staff and directed by a physician or other qualified healthcare professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate.
| Patient Consent: Inform the patient of the scope of service and potential for cost share. Document consent obtained. | Comprehensive Care Plan: Develop and maintain a detailed electronic care plan that is updated regularly, accessible to the care team, and shared with the patient. |
| Initial Visit: A qualifying visit required for new patients or patients without a visit in 3 years. | Management of Care Transitions: Coordinate follow-ups after discharges or ED visits, ensuring timely information exchange and patient/caregiver contact within 7 days post-discharge. |
| 24/7 Access: Ensure 24/7 urgent care access including a way “to contact health care professionals in the practice.” | Patient Population Data: Conduct analysis to “identify gaps in care and offer additional interventions, as appropriate.” |
| Continuity of Care: “With a designated member of the care team … the patient is able to schedule successive routine appointments.” | Risk Stratification: Segment “population based on defined diagnoses, claims, or other electronic data to identify and target services to patients.” |
| Alternative Care Delivery: Outside traditional office visits and to best meet patient’s needs, “such as home visits or expanded hours.” | Impact Analysis: Assess through “performance measurement of primary care quality, total cost of care, and meaningful use of Certified EHR.”* |
| Comprehensive Care Management: Perform thorough medical and psychosocial needs assessments, manage preventative care, and oversee medications and self-management. | *For MIPS eligible clinicians, the performance management service element can be satisfied by reporting the Value in Primary Care MIPS Value Pathway (MVP). |
2. Transition from G0511 to Specific CPT Codes for FQHCs and RHCs
Starting January 1, 2025, CMS will shift Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) from the generalized G0511 billing code to more specific CPT codes for care management services, including CCM, Remote Physiologic Monitoring (RPM), and Behavioral Health Integration (BHI). This transition aims to improve payment accuracy and transparency by using established CPT codes:
- CCM Codes: CPT 99490 (20 minutes per month), with add-ons like 99439 for extended time.
- RPM Codes: CPT 99453, 99454, 99457, and 99458, tailored to service complexity.
- BHI Codes: CPT 99484 for general behavioral health integration.
Transition Period
CMS acknowledges that providers may need time to adjust workflows. To support this, a six-month transition period will allow continued use of G0511 until June 30, 2025, providing a buffer as practices adopt the new codes.
TimeDoc Health’s Commitment to Supporting Your Team
As your trusted VCM provider, TimeDoc Health is dedicated to facilitating your adaptation to these regulatory changes. We are already developing solutions to integrate APCM services and ensure compliance with the new CPT codes. We are available to meet and discuss your specific goals, assess your needs and readiness, and bolster your commitment to delivering impactful, high-quality services and a positive patient experience. To schedule a strategy session, click here.