Is your practice ready for the Medicare care management overhaul in 2025? With CMS rolling out some of the most significant changes in recent years, providers are facing both exciting opportunities and critical adjustments. From streamlined billing codes to expanded caregiver training and a hard cap on out-of-pocket drug costs, the 2025 updates are aimed at improving patient-centered care while reducing administrative complexity.
But understanding what these updates mean—and how to align your systems and workflows accordingly—is key. Whether you’re a solo practitioner or part of a larger group practice, preparing now will position you to deliver higher quality care and secure appropriate reimbursements in this changing Medicare environment.
This blog takes a deep dive into the key changes introduced in 2025 under the Medicare Physician Fee Schedule (PFS) Final Rule, and how they affect patients, providers, caregivers, and healthcare organizations alike.
1. Launch of Advanced Primary Care Management (APCM) Services
One of the most significant changes in 2025 is the introduction of Advanced Primary Care Management (APCM) services. CMS has finalized payment for new Healthcare Common Procedure Coding System (HCPCS) codes—G0556, G0557, and G0558—that represent a consolidated, simplified care management service structure.
These services combine features of:
- Chronic Care Management (CCM)
- Transitional Care Management (TCM)
- Principal Care Management (PCM)
Unlike previous time-based billing requirements, APCM codes do not require tracking time spent on care coordination. Instead, providers may bill once per patient per month, provided they deliver the scope of services included under the APCM model. These services are typically furnished by primary care providers and their clinical staff, improving the efficiency and predictability of billing.
This change reflects CMS’s intention to shift away from fragmented services and toward a more holistic, team-based model that recognizes the continuous, relationship-driven nature of primary care.
2. New Codes and Coverage for Caregiver Training Services
Recognizing the essential role that unpaid and informal caregivers play in managing chronic illnesses, CMS has introduced new caregiver training service codes in 2025.
These services support caregivers who assist with activities such as:
- Daily living tasks (e.g., mobility, dressing, feeding)
- Medical equipment use
- Medication adherence
- Behavior management
- Infection control
Notably, these training services can be provided in-person or via telehealth, increasing accessibility for those caring for patients at home. Caregivers can now receive structured education and support without needing to be physically present at a healthcare facility.
This expansion aligns with CMS’s broader goals to reduce hospital readmissions and improve quality of life for both patients and their caregivers.
3. Expanded Telehealth Flexibility
CMS continues to prioritize telehealth in 2025, building on temporary flexibilities introduced during the COVID-19 pandemic. Some of the notable updates include:
- Telehealth reimbursement parity for services furnished to beneficiaries in their homes.
- Continued use of audio-only technology for specific services, especially behavioral health and counseling.
- Provisional coverage for caregiver training via telehealth, subject to further evaluation.
These provisions are part of CMS’s mission to close access gaps in rural and underserved areas, making it easier for Medicare beneficiaries to get timely care without travel or logistical barriers.
4. Changes for RHCs and FQHCs
CMS has also finalized rules allowing Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to bill for care management services using individual CPT/HCPCS codes rather than the general G0511 code previously required.
Key points:
- Effective January 1, 2025, with a 6-month transition window through July 1, 2025.
- Providers may now select specific codes that better reflect the services provided (e.g., chronic care vs. behavioral health integration).
- Offers greater flexibility and accuracy in billing, potentially increasing reimbursement and service transparency.
This change is particularly beneficial for providers in rural or low-income communities, where clear documentation and tailored reimbursement can significantly affect operations.
5. New Atherosclerotic Cardiovascular Disease (ASCVD) Risk Management Services
Preventive care takes center stage with the addition of ASCVD risk assessment and management services to the PFS in 2025.
These services involve:
- Risk profiling based on cholesterol levels, blood pressure, and lifestyle habits.
- Medication management (e.g., statins, aspirin).
- Counseling on smoking cessation, diet, and physical activity.
- Close monitoring of patients with moderate-to-high risk of cardiovascular events.
By creating a formal framework for ASCVD care, CMS is helping providers identify and intervene early, potentially reducing long-term hospitalizations and complications from heart disease.
6. Medicare Part D: $2,000 Out-of-Pocket Spending Cap
Perhaps one of the most consumer-friendly changes in 2025 is the implementation of a $2,000 annual cap on out-of-pocket spending for Medicare Part D beneficiaries. This measure stems from the Inflation Reduction Act and is designed to protect seniors and disabled individuals from the rising costs of prescription medications.
Highlights:
- Beneficiaries will not pay more than $2,000 out-of-pocket annually.
- New monthly payment plans will allow users to spread their expenses across the year.
- This cap applies to all Part D plans, and could offer major relief to those with chronic or complex conditions requiring multiple medications.
This is especially beneficial for those with high-cost drugs for diabetes, cancer, or autoimmune diseases.
7. 2025 Physician Fee Schedule Conversion Factor Decrease
Despite the many positive changes, one area of concern for healthcare providers is the reduction in the Medicare conversion factor.
- 2024 conversion factor: $33.29
- 2025 conversion factor: $32.35
- Net decrease: 2.83%
This adjustment stems from the expiration of temporary COVID-related payment relief and CMS’s requirement to maintain budget neutrality. Although several legislative efforts are underway to mitigate this cut, the current rate may impact the financial viability of small or rural practices already operating with slim margins.
Conclusion: What This Means for Providers and Patients
The 2025 Medicare care management changes are designed with a dual focus: enhancing patient care delivery and reducing administrative burdens for healthcare providers. From better support for caregivers to improved telehealth flexibility and preventive services, these updates reflect a strategic shift toward value-based, patient-centered care.
For healthcare providers, it’s crucial to:
- Understand new billing codes and transition timelines.
- Update Electronic Health Records (EHR) systems and workflows.
- Train staff on the new APCM service structure and telehealth options.
For patients and caregivers, the changes bring greater access, better education, and more affordable care options, especially for chronic conditions and medication management.
At expEDIum, we believe that innovation in care management must be matched by innovation in technology. Our medical billing and EHR solutions are built to help practices seamlessly adapt to CMS changes—like the 2025 updates—by ensuring compliance, simplifying billing, and optimizing care delivery. Let us help you stay a step ahead in this evolving Medicare landscape.