02 Jul Mid-year CMS Rule Updates: Are You Unsure about the Changes Ahead in 2025?
As we step into July, healthcare providers and organizations face mid-year CMS rule updates from the Centers for Medicare & Medicaid Services in the second half of 2025 that could have significant implications for billing, reimbursement, and care delivery models. From Medicare Part B and telehealth services to the ongoing transition towards value-based care, it’s vital to stay informed and prepared for these changes. Note that these changes are primarily focused on expanding and modifying existing processes, programs, and models, rather than introducing entirely new ones.
Billing Changes for RHCs and FQHCs
On July 1, 2025, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) must begin billing general care management services separately, including new advanced primary care services. These services will no longer be part of the standard all-inclusive rate (AIR). When submitting claims, RHCs and FQHCs must report these services using either code G0511 or the specific service codes — but not both.
Also, FQHCs and RHCs will be allowed to bill Medicare for the administration of Part B preventive vaccines (such as influenza, COVID-19, pneumococcal, and hepatitis B) at the time of service, starting July 1, 2025. See the news release from CMS.
Telehealth Reimbursement: What to Expect in Mid-year CMS Rule Updates
One of the most notable updates, coming in the second half of 2025, affects telehealth reimbursement policies. Over the past few years, we’ve witnessed a rapid expansion of telehealth services, especially following the COVID-19 pandemic. The CMS has been adjusting its policies to ensure that providers can continue to offer these essential services, but with changes on the horizon, it’s vital to understand the new guidelines.
Providers should review the updated CPT codes for telehealth services and familiarize themselves with any site-of-service requirements. Additionally, ensuring that you’re equipped to document and bill for these services correctly will be essential for maintaining your revenue streams.
Value-Based Care Models
The shift from fee-for-service to value-based care continues to gain momentum, and July brings updates that further emphasize this trend. The updates may include new performance metrics and reporting requirements that healthcare organizations need to incorporate into their practices.
For example, CMS announced important updates to its value-based payment model portfolio, anticipated to yield savings of $750 million as part of a strategic shift focused on cost reduction. Consequently, four payment models (one for kidney care and two affecting primary care) will be phased out by the end of 2025, before their initially set termination dates.
For those involved with Accountable Care Organizations (ACOs) or participating in other value-based models, it’s important to analyze these new measures. Understanding the impact of incentive payments and overall reimbursement will be key to optimizing your organization’s fiscal health.
Preparing for Mid-year CMS Rule Updates
Here are some steps you can take to prepare for these updates:
1. Stay Updated on Policy Changes: Ensure your team is informed about the latest CMS rule changes. Regularly check the CMS website or subscribe to updates to remain aware of changes that directly affect your practice.
2. Train Your Staff: Provide education and training to your staff on the new telehealth codes and value-based care metrics. This will help ensure everyone is on the same page and can adapt to the changing landscape.
3. Review Your Billing Practices: Conduct an audit of your current billing practices concerning telehealth services. Make sure that you’re accurately coding and capturing all eligible services to avoid revenue loss.
4. Engage with Stakeholders: Communicate with your leadership team and other stakeholders about the implications of these updates. Collaboration is key to navigating changes more effectively.
5. Consider Technology Tools: Leverage technology solutions that can support your practice in efficiently managing telehealth and reporting for value-based models. Investing in the right tools can help streamline operations and improve patient outcomes.
Preparing Now
Above all, as July begins the march toward mid-year CMS rule updates, it’s crucial to be proactive in understanding and adapting to these changes. By taking the time to prepare now, your organization can emerge more resilient and better equipped for the future of healthcare. If you have any questions or need assistance navigating these updates, contact CMS at 1-800-MEDICARE (1-800-633-4227).
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