– The Centers for Medicare & Medicaid Services (CMS) released a proposed rule outlining changes to Medicare payments under the Physician Fee Schedule (PFS) for services furnished and other Medicare Part B issues on or after January 1, 2025.
– The calendar year (CY) 2025 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a more equitable healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation for all Medicare beneficiaries.
Here’s a summary of the key proposals:
Payment and Coding
- Reduced Payment Rates: Average payment rates under the PFS are expected to decrease by 2.93% due to statutory factors.
- Conversion Factor Decrease: The PFS conversion factor, used to calculate payment rates, is proposed to decrease to $32.36 from $33.29.
- Advanced Primary Care Management (APCM): New codes and payment for a bundled service reflecting essential elements of advanced primary care like care management and communication technology.
- Cardiovascular Risk Assessment and Management: New codes and payment for assessing ASCVD risk and for risk management services.
- Strategies for Improving Global Surgery Payment Accuracy: Broader use of transfer-of-care modifiers for global surgical packages and a new add-on code for post-operative care services.
- Behavioral Health Services: Separate coding and payment for safety planning interventions for patients in crisis, payment for digital mental health treatment devices, and new G-codes for interprofessional consultation.
- Opioid Treatment Programs (OTPs): Increased payment for intake activities to include social determinants of health assessments, establishment of payment for new opioid agonist and antagonist medications, and clarification of billing requirements.
- Hospital Inpatient/Observation E/M Add-on for Infectious Diseases: New add-on code for the complexity of infectious disease care by specialists.
- Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs): Allowing general supervision of PTAs and OTAs by PTs and OTs in private practice.
- Certification of Therapy Plans: Reduced burden for therapists by allowing exceptions to physician/NPP signature on initial certifications in certain cases.
- Dental and Oral Health Services: Payment for dental services linked to covered services for End-Stage Renal Disease (ESRD) and proposing additional linked services for specific conditions.
Telehealth Services
- Addition of services to the Medicare Telehealth Services List, including demonstration prior to home INR monitoring and caregiver training.
- Continued suspension of frequency limitations for certain telehealth services.
- Allowing audio-only communication for home telehealth visits when video is not possible.
- Permitting distant site physicians to use their enrolled practice location address when providing telehealth from home (through 2025).
- Permanent adoption of a definition allowing real-time audio-visual virtual direct supervision for certain services.
- Continued virtual presence for teaching physicians in all teaching settings for services furnished involving residents (through 2025).
Other Proposals
- Request for Information (RFI) on an ambulatory specialty care model leveraging Merit-based Incentive Payment System (MIPS) Value Pathways.
- RFI on existing Community Health Integration Services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services.
- RFI on additional payment policies recognizing advanced primary care services.
- Requiring manufacturers of certain single-dose drugs to provide refunds for discarded amounts.
- Approach to payment limit calculations when negative or zero drug pricing data is reported.
- Clarification on payment methodologies for radiopharmaceuticals in physician offices.
- Modification of regulations to include certain compounded immunosuppressive drugs in the immunosuppressive drug benefit.
- Update to clarify clotting factor furnishing fees for self-administered products.
Next Steps
The public can comment on the proposed rule before it is finalized. The final rule will be published later in 2024.