RPM Manual
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Market Opportunity Brief
The Rural Arbitrage
Capitalizing on the end of G0511 and the move to unbundled care coordination billing in RHCs
Published: February 3, 2026
For Independent Pharmacy Owners
Compliance note: This resource is educational and not legal advice. RHC billing, contracting, and any pharmacy to clinic financial arrangement should be reviewed for compliance with federal and state law, payer policy, and the clinic’s Medicare Administrative Contractor guidance.
The 2026 Reality
The Shift
HCPCS G0511 is officially terminated. RHCs must now report individual CPT/HCPCS codes for care management.
The Revenue
Care coordination services are paid at national non-facility PFS rates, separate from the clinic's All-Inclusive Rate (AIR).
The Play
Pharmacies act as the "Care Coordination Engine," providing defined operational services under general supervision.
Executive Summary
Rural Health Clinics (RHCs) used to be frustrating partners for care management because a wide set of care management services were compressed into the general care management code G0511, with a single consolidated payment methodology. Beginning in 2025, CMS moved RHCs and FQHCs to unbundled reporting for “care coordination services,” meaning clinics report the individual CPT and HCPCS codes (plus applicable add-on codes) instead of relying on G0511. CMS also allowed a transition period for clinics needing time to update billing systems.
By 2026, CMS messaging is explicit that G0511 is terminated, and RHCs are operating in the unbundled world where care coordination services are paid at the national non-facility Physician Fee Schedule rate and are not folded into the RHC all-inclusive rate.
This is a real opportunity for independent pharmacies, not because “rules flipped overnight,” but because the payment mechanics now support a scalable operating partner model. RHCs can bill the component codes for RPM, CCM, APCM, and other care coordination services, but many lack the staffing and operational systems to execute these programs. Pharmacies already have the patient relationship, the refill cadence, and the workflow discipline to run the work as a contracted operating partner.
I. The timeline: what actually changed and when
2018–2023: Consolidated billing via G0511
CMS policy paid RHCs and FQHCs for care coordination services when G0511 was billed, with coinsurance and deductible rules applying on RHC claims.
2024: G0511 expanded for multiple units
CMS allowed RHCs to bill G0511 multiple times per month if requirements were met and no double counting occurred. This was a temporary reprieve but didn't solve the "single-code mindset."
2025: Unbundling begins & Transition Period
Starting Jan 1, 2025, RHCs began reporting individual codes. A grace period existed through September 30, 2025, for clinics to update legacy systems. [5]
2026: The New Operating Reality
CMS confirms G0511 is terminated. All care management services designated as "care coordination" are now paid at the national non-facility PFS rate. [1][2]
II. The old world: why G0511 constrained partnerships
G0511 bundled nearly every care management service into a single monthly payment. That structure forced RHCs to protect the AIR, cap vendor costs, and avoid external partners because there was no way to prove that incremental RPM, CCM, or APCM work created incremental revenue.
Operationally, G0511 also pushed care management into a compliance-first posture: clinics had to track minutes, document encounters, and protect against overlap across services, all while receiving a fixed payment. The math made most pharmacy-clinic collaborations feel risky rather than accretive.
III. The new world: unbundled and paid separately from the RHC AIR
The fact pattern that matters in 2026 is simple and CMS-stated:
1. Individual CPT/HCPCS Reporting
RHCs bill the specific codes for each service (RPM, CCM, APCM, TCM, etc.). This list includes base codes and all applicable add-on codes. [2]
2. Paid at National Non-Facility PFS Rate
Payment is no longer folded into the RHC All-Inclusive Rate (AIR). These costs are reported in the non-reimbursable section of the clinic's cost report. [2][3]
3. General Supervision Enabled
Face-to-face services are not required. Auxiliary personnel (including pharmacy staff) may provide services under general supervision, removing the physical-location barrier. [2]
4. Exclusivity Constraint
RHCs cannot bill if another practitioner or facility bills for that patient during the same period. Your program must be the clinic’s primary engine for that service. [2]
IV. What RHCs can bill in 2026: the practical short list
| Service Type | Primary Codes | Pharmacy Strategic Value |
|---|---|---|
| RPM (Remote Physiologic Monitoring) | 99453, 99454, 99457, 99458 | Supports device logistics and data monitoring workflows without the old G0511 abstraction. |
| CCM (Chronic Care Management) | 99490, 99487, 99491 | The foundational program for rural panels with multiple chronic conditions. High-volume opportunity. |
| APCM (Advanced Primary Care Management) | G0556, G0557, G0558 | Not time-based. Can be billed monthly. Allows for BHI/Psych CoCM add-ons in 2026. |
| Behavioral Health Integration | 99484, 99492, 99493 | Individual codes replace old bundled behavioral codes, allowing RHCs to match actual workload. [2][5.2] |
VI. The pitch script: how to walk into an RHC and not sound like a vendor
Use this accurate, compliant script to frame the conversation:
“CMS moved RHC care coordination away from the old G0511 consolidated approach. Starting in 2025, RHCs report the individual CPT and HCPCS codes and are paid at the national Physician Fee Schedule rate, separate from the All-Inclusive Rate. In 2026, CMS reminders make clear that G0511 is terminated and the component-code model is the operating reality.”
“That means the clinic can now be paid for RPM, CCM, and APCM based on the actual service mix and add-on codes. The constraint is execution. Most rural clinics do not have the staff capacity to enroll patients, manage devices, run monthly outreach, and produce audit-ready documentation.”
“My pharmacy can provide the operational layer as contracted services. You remain the billing entity and clinical authority. We provide defined operational services under a written services agreement with fair market value terms. The clinic keeps the margin and gains program capacity without hiring a new internal department.”
VIII. Risk controls: what to insist on before signing
Confirm Billing Readiness
Ensure the clinic's billing team understands individual code reporting. If they haven't updated their workflows since the G0511 sunset (Sept 30, 2025), the opportunity will be missed.
One Billing Entity Period
RHCs cannot bill if another practitioner is billing for the same period. Your program must be the exclusive engine for those service families for the clinic's patient panel. [2]
Documentation Firewall
Separate clinical documentation from dispensing operations. The clinical record must read like care coordination (RPM/CCM), not refill logistics (Part D).
Written Services Agreement
Avoid revenue shares or informal payments. Use a defined services agreement with fixed, set-in-advance fair market value (FMV) pricing. This is the only defensible posture.
FairPath note
No specific software features are assumed in this resource. Any platform used in an RHC partnership should be evaluated on whether it can support the clinic’s requirements: consent tracking, enrollment dates, monthly documentation packaging, and clean separation between dispensing operations and care coordination records. CMS materials emphasize that care coordination costs are not part of the RHC AIR and that auxiliary personnel can provide services under general supervision, which increases the need for clean workflow attribution and audit-ready artifacts.
References
- CMS Rural Health Clinics Center. CY 2026 highlights including reminder that G0511 is terminated. [1]
- CMS MLN006398. Information for Rural Health Clinics (January 2026). [2]
- CMS Medicare Benefit Policy Manual. Chapter 13 update (Rev. 13133, effective 01/01/2025). [3]
- CMS Medicare Claims Processing Manual. Chapter 9 update on unbundled care coordination. [4]
- Noridian MAC guidance on G0511 extension through September 30, 2025. [5]
FairPath is designed to handle this complexity for you.
While most platforms simply record what happened, FairPath actively runs the program. It continuously monitors every patient, staff action, and billing rule across CCM, RPM, RTM, and APCM, intervening immediately when a requirement is missed.
This allows you to scale your own program without losing quality, breaking trust with physicians, or losing control of your revenue. We provide the precision of an automated medical director without the chaos.
