CMS’s 2025 Physician Fee Schedule outlines new proposed regulations for RHCs and FQHCs such as productivity standards and general and primary care management.
At the beginning of July, CMS released the 2025 Proposed Physician Fee Schedule (PFS). The document outlines several new proposed regulations for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Here are the key points:
Productivity standards
RHCs have been subject to productivity standards since the 1970s. These standards were first implemented to help determine the average cost per patient for Medicare reimbursement and identify situations where costs would not be allowed.
During the COVID-19 pandemic, CMS relaxed the RHC productivity standards to respond to concerns that implementing appropriate measures to keep staff and patients safe would not allow RHCs to achieve these standards, and would negatively impact payments for RHCs.
In addition, the 2021 Consolidated Appropriations Act restructured payment limits for RHCs. As a result of the restructured payments, and in response to feedback that the “visit per FTE” is too high for practitioners to reasonably meet, CMS is proposing to remove productivity standards for RHCs.
General care management
CMS has continually expanded the scope of HCPCS code G0511 to include additional care management activities. Before 2024, CMS paid HCPCS code G0511 based on the national average non-facility PFS payment rate for each of the base codes included within code G0511.
In the 2024 PFS, CMS changed the methodology for calculating the value of code G0511 to a weighted average of the services that comprise the code based on utilization data for those services in the physician office setting.
After making these changes, interested parties requested CMS give them the ability to bill Medicare for each of the services that comprise HCPCS code G0511 when furnished in RHCs and FQHCs. Chief among the concerns for interested parties raising this issue is receiving more exposure and recognition for their part in delivering primary care, and the ability to develop data showing the utilization of their services that could be used in determining future payment.
In response to this feedback, CMS is proposing to require RHCs and FQHCs to bill the individual codes that make up the general care management HCPCS code G0511. Under this proposal, G0511 would no longer be payable when billed by RHCs and FQHCs. This could lead to a decrease in payment if an RHC or FQHC mostly furnishes care management services that are less than the payment amount for G0511. To address this, CMS will allow RHCs and FQHCs to bill the add-on codes for additional time spent.
Advanced primary care management services
CMS is proposing to establish coding and payment for APCM services under three new HCPCS G-codes, encompassing a broader range of services and simplifying the billing and documentation requirements of current care management codes.
To allow RHCs and FQHCs to simplify billing and documentation, CMS is proposing to allow RHCs and FQHCs to bill using these codes and receive separate payment. The proposed codes are as follows:
HCPCS Code |
Descriptor |
| GPCM1 | Advanced primary care management services 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. Various elements are required for GPCM1, which are too lengthy to list. Reach out if you have questions. |
| GPCM2 | 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, with the elements included in GPCM1, as appropriate. |
| GPCM3 | 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, with the elements included in GPCM1, as appropriate. |
Additional proposals
Additional proposals within the 2025 proposed PFS include:
- Clarification that the furnishing fee is only available to entities that provide blood clotting factors unless costs are covered by another payment system.
- Extension of telehealth flexibilities for RHCs and FQHCs, including payment for non-behavioral health visits via telecommunication technology through December 31, 2024.
- Proposal to allow virtual presence for direct supervision through December 31, 2025.
- Proposal to allow RHCs and FQHCs to bill for the administration of Part B preventive vaccines at the time of service, with annual reconciliation of payments.
- Proposal to rebase the FQHC market basket to reflect a 2022 base year, updating cost weights and price proxies from the existing 2017-based basket.
- Clarification that dental services inextricably linked to covered medical services are billable in RHCs and FQHCs, with the use of a modifier to indicate medical necessity.
- Proposal to remove hemoglobin and hematocrit tests from the list of required laboratory services RHCs must provide directly.
How we can help
Wondering how RHCs could be impacted if productivity standards are eliminated? Our financial modeling team can help you undercover this and many other important metrics.
Curious to learn more about the new codes to be used by FQHCs and RHCs? Our reimbursement and coding teams can help you decipher the changes.
Interested in how the proposals within the 2025 PFS will impact your organization? Reach out to CLA today. Our team of health care professionals can help you assess the impacts, model financial results, and craft a plan to implement new proposals.
Want to learn more? Complete the form below and we'll be in touch. If you are unable to see the form below, please complete your submission here.Contact us