Billing Changes for FQHCs & RHCs: What You Need to Know for Remote Patient Monitoring in 2025

Starting January 1, 2025, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will undergo significant billing changes for care coordination services, including Remote Patient Monitoring (RPM). The Centers for Medicare & Medicaid Services (CMS) is shifting away from HCPCS code G0511 and requiring clinics to use individual CPT and HCPCS codes that specifically describe the services provided.

This transition represents a major step toward more precise billing, improved reimbursement opportunities, and better service transparency. Below, we break down these changes, how they impact RPM, and what clinics must do to prepare before July 1, 2025.

Transition from HCPCS Code G0511 to Individual CPT/HCPCS Codes

Historically, FQHCs and RHCs have used HCPCS code G0511 to bill for various care coordination services, including RPM and chronic care management. Effective January 1, 2025, CMS mandates that these clinics bill using specific CPT and HCPCS codes that accurately reflect the provided services.

This change enables better tracking of the services delivered while allowing for more accurate reimbursement. Clinics will no longer submit claims under the generic G0511 code but will instead use a range of codes tailored to the type of care provided.

Billing Changes for Remote Patient Monitoring (RPM)

With this shift, FQHCs and RHCs must now use the following CPT codes to bill for RPM services:

CPT 99453 – Initial setup and patient education on using RPM equipment.
CPT 99454 – Monthly device supply, collection, and transmission of physiologic data.
CPT 99457 – First 20 minutes of remote physiologic monitoring treatment management services.
CPT 99458 – Each additional 20 minutes of treatment management services.

These changes not only bring FQHCs and RHCs in line with traditional Medicare billing but also provide a clearer pathway for reimbursement of RPM services.

Key Differences from G0511:

• Clinics can now bill per specific RPM service rather than a bundled rate.
• The new structure allows clinics to bill more accurately based on patient needs and the level of engagement.
• These codes align with the broader Medicare Physician Fee Schedule (PFS), making reimbursement more standardized.
  

Reimbursement Rates & Financial Impact

The transition from G0511 to individual CPT codes may result in increased reimbursement opportunities for clinics providing RPM services. Here’s what to expect:

• G0511 (2024 rate: $72.98 per month) covered multiple services under a single bundled payment.
• New CPT Codes (2025) enable clinics to bill for each aspect of RPM separately, potentially increasing total monthly reimbursement if multiple services are provided.
• FQHCs and RHCs may bill for multiple RPM-related codes per patient, increasing total revenue opportunities.

What This Means for FQHCs and RHCs

1. Increased Reimbursement Potential – The ability to bill for each RPM service separately means that clinics tracking and managing patient data effectively may see higher payments.
2. More Administrative Requirements – Clinics must ensure that claims are coded correctly to avoid denials or delays in reimbursement.
3. Alignment with Value-Based Care Trends – By adopting these codes, FQHCs and RHCs position themselves to better integrate RPM into their care models, improving patient engagement and outcomes.

Preparing for the Transition

1. Educate Your Billing & Coding Teams

   Ensure that staff members understand the new coding structure and are trained on how to properly submit claims under the updated requirements. Consider hosting training sessions or providing reference materials for easy access.

   
   

2. Update Internal Billing Systems

   Modify your clinic’s billing software to accommodate the individual CPT codes for RPM and other care coordination services. Ensure compatibility with your electronic health record (EHR) system to streamline coding and claim submissions.

   
   

3. Stay Informed with CMS Updates

   CMS may provide further guidance leading up to the transition. Regularly check their official updates and participate in webinars or training sessions offered by CMS or industry associations.

   
   

4. Monitor Reimbursement Trends

   After implementing the new billing process, track reimbursement patterns closely. This will help identify any inconsistencies or opportunities for further optimization.

The shift away from G0511 to individual CPT codes for RPM and care coordination represents a significant change for FQHCs and RHCs. While this transition requires additional administrative effort, it also provides an opportunity for clinics to receive more accurate and potentially higher reimbursement rates.

By preparing early, educating teams, and staying informed, clinics can ensure a smooth transition and continue to provide high-quality patient care while maximizing reimbursement potential.

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