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Major Updates from the 2025 Medicare Physician Fee Schedule Proposed Rule

The 2025 Medicare Physician Fee Schedule Proposed Rule could bring significant changes to how practices are reimbursed by Medicare. In addition to a new conversion factor for all practices, the Proposed Rule introduces major billing changes and a brand-new service, called Advanced Primary Care Management, which could transform how practices and health systems engage in preventative care. 

If your practice or health system serves Medicare patients, it’s time to prepare for the changes 2025 will bring to the Physician Fee Schedule. We’ll break down how your reimbursements could change and the new programs that could bring an unprecedented level of care to your Medicare patients. 

1) Changes to the PFS Conversion Factor

In the Proposed Rule, the Centers for Medicare & Medicaid Services estimate that the conversion factor for 2025 will be 32.3562. In 2024 the conversion factor started at 32.74, before the Consolidated Appropriations Act of March 2024 raised it to 33.29. This means that in 2025, practices could see a 2.81% decrease in their Medicare payments, leading to less revenue overall.

It’s possible Congress will once again choose to raise the conversion factor for 2025 or introduce legislation that eliminates reimbursement reductions. However, based only on the Proposed Rule, practices need to prepare for another drop in their conversion rates and reimbursements. 

2) Elimination of G0511 for RHCs and FQHCs

Throughout 2024, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) were able to bill the code G0511 for multiple forms of care management: Chronic Care Management (CCM), Behavioral Health Integration (BHI), and even Remote Patient Monitoring (RPM). 

G0511 reimbursement was higher than the reimbursement traditional ambulatory practices received for these services, and RHCs and FQHCs could bill G0511 multiple times in the same month. However, all care management services were grouped together under the same code. 

The Proposed Rule states that in 2025, code G0511 will no longer be payable for RHCs and FQHCs. Instead, RHCs and FQHCs will bill each of their care management services individually, using the same codes that traditional ambulatory practices do. For example, RHCs and FQHCs would now bill 99490 for non-complex Chronic Care Management and 99439 for additional time beyond twenty minutes of Chronic Care Management.

RHCs and FQHCs who don’t want to bill each care management service separately can consider offering a new, optional program called Advanced Primary Care Management instead. 

3) New Program: Advanced Primary Care Management

Perhaps most surprisingly, the Proposed Rule for the 2025 Medicare Physician Fee Schedule introduces a new preventative care program: Advanced Primary Care Management. Care management has long been a focus for CMS, with programs like Transitional Care Management and Chronic Care Management becoming staples for many practices.

Advanced Primary Care Management will transform preventative care by combining multiple care management and telehealth programs into a single program. The APCM program will incorporate features of:

• Chronic Care Management
• Transitional Care Management
• Principal Care Management
• Interprofessional Internet Consultation
• Remote Evaluation of Patient Videos/Images
• Virtual Check-In
• Online Digital E/M (e-Visit) 

As the name implies, Advanced Primary Care Management will be available for primary care practices, including general, geriatric, family, and internal medicine practices. But CMS also proposes that some specialists who serve as a primary source of care, like cardiologists and OB-GYNs, can offer the program. 

Risk-Stratification for Billing APCM 

One of the biggest differentiators in Advanced Primary Care Management compared to existing care management programs is that it expands eligibility to all Medicare patients. Furthermore, patients are separated into three levels, depending on the acuity of the patient. Each level has its own corresponding HCPCS codes, requirements, and reimbursements levels.

Level 1: Requirements for GPCM1

Medicare patients with one or fewer chronic conditions

Seen by the billing provider in the last 36 months

$10 per patient, per month reimbursement

Level 2: Requirements for GPCM2

Medicare patients with two or more chronic conditions

Seen by the billing provider in the last 12 months

$50 per patient, per month reimbursement

Level 3: Requirements for GPCM3

Patients with two or more chronic conditions who are Qualified Medicare Beneficiaries (QMB)

Seen by the billing provider in the last 12 months

$110 per patient, per month reimbursement

Removal of Time Thresholds

In addition to being offered to all Medicare patients, Advanced Primary Care Management differs from other care management programs because it’s not time-based. CMS has removed the minimum clinical time worked requirements for monthly care, such as the 20 minutes required under non-complex Chronic Care Management (99490). Clinical staff are expected to spend as much time on care as the patient requires. 

Clinical staff members can also adjust care based on factors like whether the patient has recently been admitted to the hospital, whether they’re ill or coping with complications from their chronic condition, and whether they’ve been taking their medications regularly. Depending on the patients’ needs, the clinical staff can help with care plans and goals, provide directions to local community resources, or assist with setting appointments and scheduling medication refills. 

Advanced Primary Care Management can take place under general supervision. This means clinical staff can perform the services, while the patient’s provider supervises the overall process. Practices are allowed to partner with care management organizations to offer APCM without overwhelming their workforce. 

APCM Service Elements

Since APCM combines the service elements of several care management programs, service providers are expected to expand their care program to meet additional needs. 

1. Consent

While all Medicare patients are eligible for Advanced Primary Care Management, they must consent to receive the services. Patients also can’t be enrolled in Advanced Primary Care Management at the same time as other care management services, like Chronic Care Management, Principal Care Management, or Transitional Care Management.

Clinical staff must ask patients if they would like to enroll and inform them that they can only be enrolled under one provider and can unenroll at any time. Patients must also agree to cost-sharing, unless they are a Qualified Medicare Beneficiary. (QMBs are exempt from copays and deductibles.) Consent must be recorded in the patient’s record. 

2. Initiating Visit for New Patients

New patients must have an initiating visit. An initiating visit is not required if the patient has been seen by the provider or another provider at the same practice within the past three years or if the beneficiary received APCM, CCM, or PCM from their provider or a provider at the same practice within the past year. 

3. 24/7 Access to Care and Care Continuity

A member of the care team with access to the patients’ health records must be available to patients 24 hours a day. The patient should be able to visit the same member of the care team for successive routine appointments, and the practice should supplement traditional office visits with accessible offerings like expanded office hours or home visits. 

4. Comprehensive Care Management

Comprehensive care management should include systematic assessments of patients’ physical and psychosocial needs, systems to ensure patients receive preventative care, and medication reconciliation, management, and assistance with self-management. 

5. Patient-Centered Comprehensive Care Plan

Care coordinators must work with patients to create, implement, revise and maintain an electronic care plan. This document needs to be accessible to everyone involved in a patient’s care, from the provider to the care team, the patient, and the patient’s caregivers. 

6. Management of Care Transitions

Care managers must oversee transitions from one healthcare setting to another, whether patients were referred to a specialist, went home after visiting the emergency department visit, or were released from a hospital or a skilled nursing facility. The care manager must exchange electronic information with other providers involved in the patient’s care and must follow up with the patient within seven days of their discharge. 

7. Practitioner, Home–, and Community–Based Care Coordination

The care manager must help patients find and receive assistance from practitioners, home– and community-based services, social service agencies, hospitals, and skilled nursing facilities, as needed. The care manager must also document the patients’ psychosocial strengths, needs, goals, and desired outcomes, while noting their cultural and linguistic preferences. 

8. Enhanced Communication Opportunities

The patient must be able to communicate with their care team and their provider through multiple methods, including secure messaging, email, Internet, patient portal, or phone. Providers should also be able to review and evaluate pre-recorded images or videos from patients. Practices must also offer digital communication options that can provide a clinical decision, like virtual check-ins or e-visits. 

9. Patient Population-Level Management 

Practices must analyze patient population data to identify gaps in care and offer interventions. They must also have the ability to risk-stratify their patients according to the three levels of APCM. 

10.  Performance Measurement

One of the most significant differences between Advanced Primary Care Management and programs like CCM or PCM is that APCM is outcomes-based. To prove that they are providing quality, cost-effective care, practitioners who are MIPS-eligible need to register for the Value in Primary Care MIPS Value Pathway. APCM is also open to providers who are enrolled in the Medicare Shared Savings Program, ACO Reach, Making Care Primary, or Primary Care First programs. All of these programs are used to track patient outcomes and evaluate whether APCM has been effective. 

Navigating the Changes to the Medicare Physician Fee Schedule

If the Final Rule is similar to the Proposed Rule, the Medicare Physician Fee Schedule will undergo major changes in 2025. Reimbursement rates for services will drop, and FQHCs and RHCs will no longer be able to bill G0511.

However, FQHCs and RHCs will gain the ability to bill care management services separately. All practices will also have the option to embrace a new care management program, Advanced Primary Care Management, which is available to all Medicare beneficiaries and ensures they have 24-hour access to care.

If you’d like to learn more about Advanced Primary Care Management and other provisions of the PFS, reach out with your questions at https://www.chartspan.com/contact-us/.

Sources

Centers for Medicare & Medicaid Services. (2024, July 10). 2025 Medicare Physician Fee Schedule Proposed Rule. Federal Register. https://www.federalregister.gov/public-inspection/2024-14828.pdf