Client Alert
09/12/2025
Key CMS Care Management Updates Effective
1. Sunsetting of G0511 for RHCs and FQHCs
- On September 30, 2025, CMS will officially retire the G0511 code — the consolidated code rural health clinics (RHCs) and federally qualified health centers (FQHCs) currently use for general care management services (e.g., Chronic Care Management, Behavioral Health Integration, Remote Patient Monitoring).
- Beginning October 1, 2025, RHCs and FQHCs must report individual care management CPT codes instead of G0511 — for example, 99490 (CCM), 99491, etc.
2. End of Transition Grace Period
- CMS allowed a transition period starting January 1, 2025, during which RHCs/FQHCs could choose between continuing with G0511 or switching to individual codes. This flexibility continues until September 30, 2025.
- After that date, G0511 can no longer be used, and billing must rely on individual CPT codes or, if chosen, the alternative APCM codes.
3. APCM (Advanced Primary Care Management) Codes Still Available
- RHCs and FQHCs have the option to bill APCM codes (G0556, G0557, G0558) instead of individual codes — based on patient complexity:
- G0556: ≤1 chronic condition — approx. $15.20/month
- G0557: ≥2 chronic conditions — approx. $48.84/month
- G0558: Dual-eligible with ≥2 conditions — approx. $107.07/month
Note: You must choose either APCM or individual CPT codes, not both for the same patient in a given month.
Summary Table
| Effective Date | Action Required |
|---|---|
| Jan 1 – Sep 30, 2025 | Optional use of G0511 or individual CPT codes (transition period) |
| September 30, 2025 | Last day G0511 may be used |
| October 1, 2025 onwards | Must use individual CPT care management codes or APCM codes (G0556–G0558) |
What This Means for You
- If you’re in RHCs or FQHCs, ensure your billing systems and workflows are updated by October 1, 2025 to use individual CPT codes for care management services—or optionally, APCM codes if that fits your patient distribution and care management structure.
- Failure to switch from G0511 by the deadline could result in denied claims or noncompliance with Medicare billing rules.