Finalized 2025 Medicare Physician Fee Schedule advances CCM and value-based care with new advanced primary care management codes

Remote physiological monitoring (RPM) and chronic care management (CCM) are well-established programs with years of operational and billing experience in many practices. These billable activities have allowed health care providers to offer more comprehensive care to Medicare beneficiaries outside of their traditional in-person doctor’s visits. Because the U.S. Centers for Medicare & Medicaid Services (CMS) views these as complementary activities, providers are also able to leverage the right program for each patient, which often means enrolling some patients in both RPM and CCM services and billing for these services concurrently.

CMS’ recently issued rule finalized changes to the 2025 Physician Fee Schedule (PFS), which includes the introduction of new Advanced Primary Care Management (APCM) Healthcare Common Procedure Coding System codes, shedding light on the potential future of CCM coding. The new PFS goes into effect on Jan. 1, 2025, furthering an evolution that underscores a significant shift toward longitudinal, outcomes-focused care. Medical practices must stay abreast of these changes to leverage platforms supporting RPM, CCM and APCM programs effectively, ultimately optimizing revenue and patient care.

Understanding differences between RPM and CCM can maximize reimbursement

Although fee-for-service care management programs are familiar to many practices, significant confusion or lack of awareness persists. RPM and CCM were introduced as reimbursable codes to provide a structured way for health care providers to deliver continuous care to patients with chronic conditions. RPM focuses on collecting and interpreting patient-generated data between doctor’s visits to enhance care decisions. In contrast, CCM focuses on establishing and managing chronic disease care plans, medication adherence and care coordination. Other key differences between the two include:

Eligibility

• RPM requires monitoring for patients with just one chronic condition.
• CCM mandates that patients have two or more chronic conditions.

Focus

• RPM is centered around remote collection and interpretation of physiological data, such as glucose levels, blood pressure and oxygen saturation.
• CCM emphasizes comprehensive care plans, regular follow-ups and medication management.

Device requirement

• RPM necessitates the use of devices to collect data.
• CCM does not require the collection of physiologic data.

Notably, health care providers can bill for RPM and CCM services concurrently, as long as the criteria for both services have been fully met. Using nonfacility national averages, providers could receive a reimbursement of $140 to $210 per patient per month for patients with two or more chronic conditions who are enrolled in both programs. The required activities for each code would need to be performed separately, including at least 40 minutes of combined clinical time, covering tasks such as clinical staff monitoring, care coordination and physician-patient communication.

Clinical benefits of RPM and CCM have been clearly established

It’s important to remember why CMS created these billable services in the first place: to facilitate a path to practicing more outcomes-focused care. RPM and CCM services offer countless benefits that extend beyond the walls of a health care facility. By leveraging technology, RPM allows for the continuous monitoring of patients’ health metrics — such as blood pressure, glucose levels and oxygen saturation — from their homes. The near real-time data collected enables proactive interventions, decreasing the likelihood of costly hospital readmissions and emergency department visits.

CCM provides comprehensive care coordination across provider teams for patients with more than one chronic condition, such as diabetes, chronic obstructive pulmonary disease (COPD), hypertension and heart disease. Through regular follow-ups, personalized care plans and patient education, CCM enhances patient self-management and adherence to treatment protocols.

There’s plenty of research demonstrating the potential of RPM and CCM to strengthen patient care and drive meaningful improvements in health outcomes. In one trial of more than 1,500 patients with heart failure, RPM reduced unplanned cardiovascular hospitalizations by 1.76 percentage points (from 6.64% to 4.88%) and all-cause mortality by 3.4 percentage points (from 11.3% to 7.9%) over 12 months compared with usual care. Similarly, another report revealed that CCM programs reduced Medicare costs by $74 per beneficiary per month over an 18-month period. Program participants’ hospital, emergency department and nursing home costs were lower, and for those with conditions — such as congestive heart failure, COPD and diabetes — CCM was linked to a lower likelihood of hospital admission.

The APCM codes signify focus on quality

The most notable change in the 2025 PFS, as it pertains to care management, is the introduction of APCM coding. Unlike CCM, APCM is not time based. Another key differentiator is that it expands eligibility to all Medicare beneficiaries, with coding divided into three levels depending on the patient’s level of acuity. APCM combines elements of multiple care management and telehealth programs into a single model that emphasizes risk stratification, comprehensive care management, 24/7 access to care and enhanced communication opportunities. The clear focus of APCM is clinical outcomes, signaling CMS’ commitment to moving away from episodic, transactional care and toward longitudinal, outcomes-focused care. Medical practices billing under APCM cannot bill CCM simultaneously, as the activities typically required for CCM would be included in APCM, but RPM remains considered a complementary service that can be billed concurrently.

Some other changes ushered in include the elimination of the G0511 billing code for RPM services provided by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Instead, FQHCs and RHCs will bill each care management service previously encompassed in G0511 individually, which could lead to higher RPM reimbursement opportunities and better programs for underserved patient populations.

The evolution of RPM and CCM, alongside the introduction of APCM, reflects CMS’ continued push toward a value-based health care system. The continued transition toward incentivizing value-based care behaviors is crucial for achieving the goal of having 100% of Medicare beneficiaries in value-based programs by 2030. For medical practices, staying informed about these developments is imperative. Health care providers who understand and properly use these codes contribute to the transformation of health care billing and care models, leading to more comprehensive, continuous care delivery and a more sustainable health care system.

Now that the final rule has been issued, it’s imperative that CCM stakeholders — health care providers and solutions providers alike — take stock of current solutions to ensure they meet the needs of the updated APCM coding.

Lucienne Marie Ide, MD, PhD, is the founder and chief executive officer of Rimidi, a digital health company that supports health care providers in the delivery of remote patient monitoring and chronic disease management with EHR-integrated software, services and connected devices.