On Friday, November 1, 2024, CMS released the calendar year 2025 Medicare Physician Fee Schedule final rule, alongside the Outpatient Prospective Payment System final rule and the 2025 Quality Payment Program policies. The physician rule runs to well over a thousand pages. We spent the weekend with the fact sheet and the payment tables, and this is the version for people who have to bill under it in eight weeks.
The headline is the one everyone expected. The conversion factor drops from $33.29 to $32.35, a 2.83% reduction, because the temporary 2.93% increase Congress added for 2024 expires and the statutory update for 2025 is zero. Unless Congress intervenes before January 1, every Medicare allowed amount falls by roughly that percentage. The rest of the rule contains several things practices can actually act on, and one of them, Advanced Primary Care Management, is the largest new primary care payment in years.
Key takeaways
- The conversion factor is $32.35 for 2025, down 2.83%. Budget for the full cut and treat any congressional relief as upside.
- Three new monthly Advanced Primary Care Management codes, G0556 to G0558, pay roughly $15, $50 and $110 per patient per month with no time requirement, and replace CCM, PCM and TCM for enrolled patients.
- G2211 becomes payable with modifier 25 when the visit is on the same day as an annual wellness visit, vaccine administration or another Part B preventive service.
- Medicare will not pay CPT 98000 to 98015; office visit codes remain the Medicare telehealth codes, and 98016 replaces G2012 for the virtual check-in.
- The statutory telehealth flexibilities still expire December 31 unless Congress acts; the rule extends only what CMS controls.
What happened, in one table
| Policy | What CMS finalized | Effective |
|---|---|---|
| Conversion factor | $32.35, down 2.83% from $33.29 | January 1, 2025 |
| Advanced Primary Care Management | New HCPCS codes G0556, G0557 and G0558, billed monthly per patient | January 1, 2025 |
| G2211 complexity add-on | Payable with modifier 25 when the visit is on the same day as an annual wellness visit, vaccine administration or another Part B preventive service | January 1, 2025 |
| CPT 98000 to 98015 | Not recognized for Medicare payment (status indicator I); office visit codes continue to be used for telehealth | January 1, 2025 |
| CPT 98016 | Recognized, replacing the virtual check-in G2012 | January 1, 2025 |
| Audio-only telehealth | Permitted for any telehealth service to a patient at home when the patient cannot use or does not consent to video | January 1, 2025 |
| Virtual direct supervision | Extended through December 31, 2025; made permanent for a limited set of services | January 1, 2025 |
| Practitioner home address | Practitioners may continue to report their enrolled practice location instead of their home when furnishing telehealth from home, through 2025 | January 1, 2025 |
| Caregiver training | New codes for training caregivers in wound care, infection control and pressure injury prevention, available via telehealth | January 1, 2025 |
The Advanced Primary Care Management codes
This is the change we think primary care practices should spend the most time on. APCM bundles elements of chronic care management, principal care management, transitional care management and the communication technology-based services into a single monthly code, with no minimum time requirement. There are three levels, set by patient complexity rather than minutes:
- G0556: patients with one or fewer chronic conditions. National payment in the 2025 tables is about $15 per month.
- G0557: patients with two or more chronic conditions. About $50 per month.
- G0558: patients with two or more chronic conditions who are Qualified Medicare Beneficiaries. About $110 per month.
The practitioner who bills must be the patient's continuing focal point for primary care and must be able to deliver the full set of service elements: 24/7 access, continuity with a designated care team member, comprehensive care management, an electronic care plan, management of care transitions, coordination with home and community services, enhanced communication channels, population-level data review, risk stratification and participation in performance measurement (through the Shared Savings Program, ACO REACH, Primary Care First or the Value in Primary Care MIPS Value Pathway). Patient consent is required, and cost sharing applies except for QMB patients, which is the reason G0558 is valued highest: the practice cannot collect the coinsurance from a QMB and the payment is set to reflect that.
We will publish a coding guide for APCM and G2211 in December. For now, the question for a practice is simpler: can we deliver all of those elements to a defined panel, and how many of our Medicare patients have two or more chronic conditions? Those two answers decide whether APCM is worth building. A practice that never billed CCM because time tracking was the barrier should look hardest, because APCM is payment for coordination work it is probably already doing.
G2211: the modifier 25 door opens a little
Since G2211 became payable in 2024, it has been blocked whenever the office visit carried modifier 25. That has excluded the most common primary care scenario: a problem-oriented visit on the same day as a flu shot or an annual wellness visit. For 2025 CMS allows G2211 with modifier 25 when the same practitioner performs the office visit on the same day as an annual wellness visit, vaccine administration or any Medicare Part B preventive service. The exception does not extend to other same-day procedures. An office visit with modifier 25 alongside a joint injection still cannot carry G2211. The add-on itself pays about $16 in 2024 and slightly less in 2025 after the conversion factor change.
The telemedicine codes: Medicare says no to 16 of 17
The AMA's CPT 2025 set introduced 17 telemedicine E/M codes, 98000 to 98016. CMS finalized its position that there is no programmatic need to pay for 98000 through 98015, assigning them a status indicator of I, meaning a more specific code exists (the office visit codes reported with the telehealth place of service or modifier). Only 98016, the brief virtual check-in, is recognized, replacing G2012. Practices therefore keep two workflows: 99202 to 99215 with POS 02 or 10 for Medicare telehealth, and the 98000 series for any commercial payer that chooses to adopt it.
The rule also confirms what it cannot fix. The statutory flexibilities that allow Medicare patients to receive telehealth at home, outside rural areas, and from an expanded set of practitioners expire on December 31, 2024 unless Congress extends them. CMS extended what it controls, such as virtual direct supervision and the practitioner home address policy, through 2025, and it broadened the definition of an interactive telecommunications system so that audio-only is permitted for a patient at home who cannot or will not use video. The geographic and originating site rules are up to Congress, and nothing in this rule changes that.
Modeling the cut for your practice
The 2.83% figure is abstract until it is applied to the practice's own numbers, and owners should see it before January. The arithmetic is short. Take Medicare Part B collections for the last twelve months, multiply by 2.83%, and that is the annual reduction at constant volume. Then find every Medicare Advantage and commercial contract that is expressed as a percentage of the current Medicare fee schedule, because those follow the conversion factor automatically, and add their collections to the base.
| Revenue source | Trailing 12 months | Follows the conversion factor? | 2025 reduction at constant volume |
|---|---|---|---|
| Medicare Part B | $1,200,000 | Yes | About $34,000 |
| MA plan A (100% of current Medicare) | $450,000 | Yes | About $12,700 |
| MA plan B (fixed 2024 schedule in contract) | $300,000 | No | $0 |
| Commercial (own fee schedule) | $900,000 | No | $0 |
| Total exposure | About $46,700 |
The same table is where APCM belongs. If that practice has 600 Medicare patients with two or more chronic conditions and can enroll half of them, G0557 at about $50 a month is roughly $180,000 a year before cost sharing and before the work of delivering the elements. Whether that is realistic depends on the practice; the point is that the cut and the new code sit on the same page, and most practices only look at the first.
OPPS and MIPS, briefly
The Outpatient Prospective Payment System final rule, released the same day, increases hospital outpatient and ambulatory surgical center payment rates by 2.9% for 2025. Independent practices feel that indirectly, through site-of-service differentials and ASC arrangements. The 2025 Quality Payment Program policies keep the MIPS performance threshold at 75 points, keep the payment adjustment range at plus or minus 9%, hold the data completeness requirement at 75% through the 2028 performance period, and add six new MIPS Value Pathways, bringing the total to 21. Practices that expected the threshold to rise can stop worrying about that for one more year.
Questions we hear
Will Congress fix the cut?
We don't know. Congress has softened or reversed cuts in each of the last several years, usually late and sometimes retroactively; the 2024 relief arrived in March with a March 9 effective date. Budget for the cut and treat any relief as upside, and make sure your fee schedule supports effective-dated lines in case relief arrives mid-year again.
Can we bill APCM and chronic care management for the same patient?
Not in the same month by the same practitioner. APCM replaces CCM, PCM, TCM and the virtual communication codes for that patient. Remote physiologic monitoring is billed separately, but read the final rule's list before assuming anything else is.
Does the rule affect Medicare Advantage plans?
Indirectly. Many MA contracts pay a percentage of the current Medicare fee schedule, so the cut flows through; some lock a schedule year in the contract and do not. MA plans set their own policies on G2211, APCM and the telemedicine codes, and in our experience they publish them between December and March.
What to do this month
- Load the 2025 Medicare fee schedule with the January 1 effective date, and reprice every Medicare Advantage contract that is expressed as a percentage of Medicare.
- Build the exposure table above from your own trailing twelve months so the owners see the number before January.
- Count Medicare patients by number of chronic conditions and QMB status; the eligibility response carries the QMB indicator.
- Decide whether to build APCM, and if so, which practitioner bills it for each patient.
- Update the G2211 claim edit to allow modifier 25 in the preventive-service scenario and block it elsewhere.
- Keep the office visit codes for Medicare telehealth and map 98016 in place of G2012 for Medicare dates of service from January 1.
- Brief providers that the home-based telehealth rules for Medicare patients are still uncertain after December 31, and tag January telehealth visits so they can be converted if needed.
- Revelrex loads the January fee schedules for practices on our medical billing service, and the December session of our RCM training walks through the rule's coding changes with worked claims.
