Upcoming Changes in DME Billing for Chronic Disease Management

Chronic disease management significantly benefits from Durable Medical Equipment (DME) as it offers necessary medical devices that patients need to track and uphold their health. The Centers for Medicare & Medicaid Services (CMS) started making substantial revisions to DME billing procedures for 2025 as healthcare policies continue changing. These billing system updates strive to unite healthcare providers to improve patient care, simplify payment processing, and reward value-based care approaches. The modifications require complete understanding from healthcare providers working with patients who manage chronic diseases.

Key Changes in DME Billing for 2025

1. Elimination of HCPCS Code G0511 for Care Coordination Services

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) applied HCPCS code G0511 throughout history to submit bills for their Chronic Care Management (CCM) services. The Centers for Medicare and Medicaid Services (CMS) will discontinue its use of code G0511 starting January 1, 2025, as they plan to introduce individual CPT and HCPCS codes for improved billing specificity. The transition brings greater clarity about the services that lead to precise reimbursement payments.

2. Transition to Individual CPT Codes

The removal of G0511 requires healthcare providers to use specific Clinical Procedure Terminology codes for Chronic Care Management documentation and accurate reimbursement processes:

• CPT Code 99490 – Non-complex Chronic Care Management services requiring at least 20 minutes of clinical staff time per month.
• CPT Code 99439 – Additional time spent on Chronic Care Management beyond the initial 20 minutes.

This change aligns payments with the complexity and duration of care coordination activities, ensuring fair compensation for RHCs and FQHCs.

3. Introduction of Advanced Primary Care Management (APCM) Services

Under the 2025 Medicare Physician Fee Schedule (PFS) the Centers for Medicare & Medicaid Services (CMS) introduces Advanced Primary Care Management (APCM) services. APCM organizes multiple healthcare management services to support primary care physicians in their mission to provide organized patient-centric care.This initiative integrates elements of:

• Principal Care Management (PCM)
• Transitional Care Management (TCM)
• Chronic Care Management (CCM)

The strategy proves to be beneficial for patient care by assisting primary care doctors in creating improved treatment organizations for patients who have prolonged health concerns. Through APCM, CMS intends to unite different care management systems while eliminating unnecessary office work so providers can provide more attention to patient assessment.

To facilitate the implementation of APCM, CMS has introduced three new HCPCS G-codes:

• G0556: For patients with a single chronic condition requiring ongoing management.
• G0557: For patients with two or more chronic conditions requiring active care coordination.
• G0558: For patients with multiple chronic conditions who are also Qualified Medicare Beneficiaries (QMBs), meaning they are eligible for additional financial assistance.

Through these codes administrators no longer need to use time-based restrictions which decreases administrative workloads. APCM payment systems adjust financial compensation based on patient health requirements to allow for personalized long-term care administration.

4. Impact on RHCs and FQHCs

APCM services present an excellent opportunity for both RHCs and FQHCs to enhance their patient care practices. The centers can engage in APCM services by using the national non-facility PFS payment rates when they submit claims containing suitable APCM codes.

The coding shift delivers dual benefits to healthcare facilities since it both strengthens their financial status and allows better coordination between services and improved patient oversight with better health outcomes. An organized payment system enables RHCs and FQHCs to maximize resources for enhancing their premium healthcare services to underserved communities.

5. Six-Month Transition Period

The Centers for Medicare & Medicaid Services (CMS) provides a six-month transition period from January 1, 2025, up to at least July 1, 2025, to ease the implementation of this change. The six-month planning period requires healthcare practitioners to modify their billing procedures and train their teams while incorporating new CPT and HCPCS codes into their operational workflow.

The transition timeframe serves as the paramount factor in maintaining legal compliance and uninterrupted insurance claim processing. The transitional period provides healthcare entities with a chance to review billing procedures, identify errors, and enhance documentation systems.

6. Enhancements in Telehealth Services

Starting January 1, 2025, CMS proposes allowing real-time, two-way audio-only telehealth services when:

• A distant-site physician has access to video technology.
• The patient is unable or unwilling to use video conferencing.

Patients in rural locations or areas with limited technology experience now receive better medical care through this system modification.CMS seeks to improve medical care delivery for patients with chronic diseases through their expansion of telehealth services which combines reduced hospital visits and better medical access.

7. Integration of Remote Patient Monitoring (RPM) with CCM

The 2025 PFS Final Rule emphasizes the integration of Remote Patient Monitoring (RPM) with Chronic Care Management (CCM) services. Key points include:

• Providers can offer RPM alongside CCM.
• RPM supports its own CPT billing codes, allowing dual reimbursement.
• RPM service and time requirements must be met separately from CCM.

This integration enables providers to bill separately for both services, provided that RPM requirements are met independently. By leveraging wearable devices, smart sensors, and continuous data tracking, healthcare professionals can proactively adjust treatment plans and prevent complications, leading to improved patient outcomes and reduced emergency visits.

Emphasis on Value-Based Care

These changes reflect CMS’s commitment to advancing value-based care by:

• Implementing APCM services for personalized care.
• Expanding telehealth services for improved accessibility.
• Integrating RPM with CCM for real-time patient monitoring.
• Refining billing codes for streamlined reimbursements.

Value-based care reimbursements are tied to the quality of services provided, incentivizing healthcare providers to invest in better care models, reduce inefficiencies, and prioritize patient well-being. The updated payment method provides healthcare organizations with enhanced capabilities regarding long-term illness management.

Conclusion

The upcoming DME billing changes for chronic disease management in 2025 signify a transformative shift toward more personalized, coordinated, and value-based care. Healthcare providers operating within RHCs and FQHCs need to implement these modifications as they will help maximize reimbursements while delivering better patient care.

The updated knowledge and utilization of these modifications enable healthcare providers to maintain simplified billing operations which results in better care outcomes for chronic disease patients. Healthcare providers should consider using medical and billing services provider company 24/7 Medical Billing Services as their outsourced partner to navigate complex changes and meet billing regulations.

FAQs 

Q1. What is the billing code for chronic disease?

Healthcare practitioners primarily rely on CPT 99490 for Chronic Care Management (CCM) and CPT 99439 for additional time to invoice chronic disease management services.

Q2. What is the DME code range?

Medical Durable Equipment (DME) has its billing codes located between E0100–E9999 in Level II of the HCPCS system to represent multiple types of durable medical equipment.

Q3. How to identify a DME code?

The explicit list of DME codes exists in the HCPCS Level II manual where each code begins with an “E” while following specific equipment types.

Q4. What is the limit of DME?

Medicare typically covers 80% of the approved amount for DME after the deductible, with limitations based on medical necessity, frequency, and lifetime restrictions for certain equipment.