Beyond the Visit: How Remote Care (RPM & CCM) Is Transforming FQHCs and RHCs in 2025

Written by David Medeiros | Feb 26, 2025 4:09:45 AM

The Evolving Landscape of Remote Care for FQHCs & RHCs

For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), keeping up with evolving value-based care models has long been a challenge. Limited funding, provider shortages, and outdated reimbursement models have made it difficult to expand care beyond in-person visits.

However, in 2024, CMS expanded reimbursement opportunities for Remote Patient Monitoring (RPM) and Chronic Care Management (CCM), empowering FQHCs and RHCs to leverage remote care programs as a sustainable, scalable solution. 2024 marked a significant expansion of the G0511 (general care management) procedure code for FQHCs. For the first time, Remote Physiologic Monitoring (RPM), Remote Therapeutic Monitoring (RTM), and Principal Care Management (PCM) interactions became reimbursable under the “umbrella” of G0511.

As of January 2025, new CPT-based billing replaces the G0511 code, providing higher reimbursement rates and enabling providers to bill separately for RPM and CCM—creating a clearer path to financial sustainability and bringing FQHC billing more in line with private fee-for-service payment structures

So, is remote care worth it for FQHC or RHC?

Let’s explore how RPM and CCM work, their benefits, and the latest CMS reimbursement updates to help you decide.

What are RPM & CCM?

Remote Patient Monitoring (RPM)

RPM allows providers to track patient vitals remotely using connected devices like blood pressure monitors, glucometers, and pulse oximeters. Data is automatically transmitted to clinical teams, allowing for early intervention, reduced hospitalizations, and better chronic disease management.

Chronic Care Management (CCM)

CCM focuses on coordinated care for patients with two or more chronic conditions, offering:

Personalized care plans
Monthly patient check-ins & care coordination
Medication management & health coaching

While RPM captures real-time patient data, CCM ensures proactive engagement and treatment adherence. Together, they create a complete remote care model that helps FQHCs & RHCs improve patient outcomes while optimizing operational efficiency.

Why FQHCs & RHCs Are Adopting RPM & CCM

1. Improved Patient Outcomes

RPM enables early detection of health issues, reducing hospitalizations and ER visits.
CCM improves long-term disease management, ensuring better adherence to care plans.

Example: A Louisiana-based FQHC implemented RPM, resulting in:

24 mmHg reduction in systolic BP
97 mg/dL reduction in blood glucose
$302,000 in cost savings due to fewer ER visits

2. Increased Access to Care

Many FQHC/RHC patients struggle with transportation and financial barriers, making it difficult to receive consistent care.
RPM & CCM reduce the need for frequent in-person visits, providing consistent care at home.

3. Financial Sustainability & New Revenue Streams

With CMS shifting away from G0511 in 2025, FQHCs can now bill:

RPM for real-time monitoring & interventions.
CCM for ongoing care coordination & management.
Extension time codes (99458 and 99439) that allow a full hour of billable clinical time to be spent with a patient in a calendar month, not the previously instated 20-minute cap.

4. Reduced Staff Burden & Increased Efficiency

RPM reduces in-clinic workload by automating patient monitoring.
CCM provides structured patient engagement, preventing last-minute urgent visits.
Both of these services can be fulfilled by third-party clinical teams so as to not overload staff members.

Fact: CCM has been shown to reduce hospitalizations by 28%, giving patients continuous support without the need to travel into the clinic.

How RPM & CCM Work Together in FQHC & RHCs

Step 1: Identify Eligible Patients

CCM: Patients with 2+ chronic conditions requiring ongoing care and have been seen for an office visit in the past 12 months.
RPM: Patients with at least one chronic condition needing continuous monitoring of vitals (e.g., CHF, hypertensive, diabetic) and have been seen for an office visit in the past 12 months.

Step 2: Device Setup & Patient Education

RPM: Patients receive cellular or Bluetooth-enabled devices to track vitals.
CCM: Nurses develop personalized care plans and conduct monthly patient check-ins, coordinating with the patient’s care team as needed.

Step 3: Data Collection & Monitoring

RPM: Vital signs are automatically transmitted for review by the patient's nurse care manager and provider (if needed).
CCM: Care coordinators engage patients longitudinally, documenting care, gap closure, SDOH, etc., and adjust care plans accordingly.

Step 4: Proactive Interventions

RPM alerts for abnormal readings are reviewed by the nurse care manager, and providers are engaged to facilitate interventions as needed.
CCM nurses help to close gaps in care with patients, address SDOH, coordinate care, and engage the patient’s provider and/or care team when interventions are required.

2025 CMS Reimbursement Updates: RPM & CCM Billing for FQHCs

With G0511 eliminated in 2025, FQHCs & RHCs must transition to CPT-based billing by July 1, 2025.

New RPM CPT Codes

99453 – One-time payment for patient device setup
99454 – Monthly reimbursement for 16+ days of transmitted data
99457 – First 20 minutes of remote monitoring & treatment management that includes dialogue between clinical staff and patient
99458 – Each additional 20 minutes of remote monitoring & treatment management

New CCM CPT Codes

99490 – First 20 minutes of clinical staff time spent providing chronic care management services per month
99439 – Each additional 20 minutes of clinical staff time spent per month

DIY Solutions and Programs vs. Full Service

Most people reading this are an ambitious bunch. You are a leader/provider/administrator of a health system that might have HRSA funding or the green light to build a remote care program, and you are researching how to start.

One thing that you’ll notice is that this RPM thing isn’t all that complicated… until it is.

First, you buy devices.

What kind are they?

Do you choose Bluetooth devices that require your aging population to sync them to wifi they might not have?
Do you choose cellular-enabled devices that will transmit the info directly to your chosen location?

Then, you map out where all that patient health information will be stored.

Where do you even store that volume of data?

Locally on site?
Off-site?
How do you secure that volume of data?
If you have to participate in an audit, can you provide documentation of secure information transfers?

Then, you train your staff on 1) monitoring incoming data and 2) training patients on how to use their new devices.

Do you have the staff bandwidth or the budget to hire new staff?

So, if you’re considering building your own remote care program, be aware of some of these considerations.

What 2025 Means for FQHCs & RHCs:

Higher reimbursements compared to G0511
RPM & CCM extension time-based codes increase revenue potential
Deadline: Transition to CPT billing by July 1, 2025

Is Remote Care Worth It for Your FQHC or RHC?

The answer is yes—when implemented effectively. RPM & CCM programs have already proven their value, improving patient health, reducing costs, and increasing provider efficiency.