Introduction
The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule for the Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS). This rule, set to take effect on January 1, 2025, outlines numerous policy changes aimed at creating a more equitable healthcare system. These changes promise to enhance accessibility, quality, affordability, and innovation for all Medicare beneficiaries.
Background on the Physician Fee Schedule
Since its inception in 1992, the Medicare PFS has governed payments for physician services. Payments under the PFS vary based on the setting, such as physician offices, hospitals, and ambulatory surgical centers (ASCs). The system uses Relative Value Units (RVUs) to determine payment rates, which reflect the resources typically used to furnish the service. These RVUs are adjusted for geographic cost variations and are converted into payment rates through a conversion factor.
CY 2025 PFS Rate Setting and Conversion Factor
For CY 2025, the CMS proposes a reduction in average payment rates by 2.93% compared to CY 2024. This decrease incorporates a 0.00% overall update, the expiration of a 2.93% increase from CY 2024, and a minor 0.05% adjustment for changes in work RVUs. Consequently, the proposed conversion factor for CY 2025 is $32.36, down from $33.29 in CY 2024.
Improving Ambulatory Specialty Care
The CMS is exploring a new model for ambulatory specialty care that leverages the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). This model aims to increase specialist engagement in value-based care and enhance primary and specialty care coordination. Feedback is being solicited to refine this potential model.
Caregiver Training Services (CTS)
New coding and payment for caregiver training services are proposed, covering topics such as ulcer prevention, wound care, infection control, and medication administration. These services may also be delivered via telehealth, expanding their accessibility.
Services Addressing Health-Related Social Needs
The CMS is seeking input on Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment. The goal is to refine policies to better address health-related social needs, especially in rural areas.
Office/Outpatient (O/O) Evaluation and Management (E/M) Visits
For CY 2025, the CMS proposes to allow payment for the O/O E/M visit complexity add-on code G2211 when reported with an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service in the office or outpatient setting.
Telehealth Services under the PFS
Several services are proposed for provisional addition to the Medicare Telehealth Services List, including home INR monitoring and caregiver training services. The CMS also proposes continuing the suspension of frequency limitations for specific telehealth services and allowing audio-only communication technology for certain telehealth services.
Advanced Primary Care Management Services (APCM)
New coding and payment for APCM services are proposed, integrating elements from existing care management services into a bundle. This includes Principal Care Management, Transitional Care Management, and Chronic Care Management. Performance measurement for these services would begin in 2026.
Cardiovascular Risk Assessment and Management
To enhance cardiovascular care, the CMS proposes new coding and payment for ASCVD risk assessment and management services. These services will focus on risk factors such as blood pressure, cholesterol, and smoking status, aiming to reduce the risk of cardiovascular disease.
Strategies for Improving Global Surgery Payment Accuracy
The CMS proposes requiring the use of transfer of care modifiers for all 90-day global surgical packages. This change aims to provide more accurate information on the resources involved in global surgical services, leading to better payment accuracy.
Behavioral Health Services
New proposals include separate coding and payment for safety planning interventions for patients in crisis, including those at risk of suicide or overdose. The CMS also proposes payments for digital mental health treatment devices and services provided by behavioral health specialists.
Opioid Treatment Programs (OTPs)
Proposed changes include telecommunication flexibilities for OTPs and updates to payment for new opioid agonist and antagonist medications. These changes aim to improve access to opioid use disorder (OUD) treatment.
Hospital Inpatient or Observation (I/O) Evaluation and Management (E/M) Add-on for Infectious Diseases
A new HCPCS add-on code is proposed for hospital inpatient or observation care associated with infectious diseases. This code includes elements such as disease transmission risk assessment and complex antimicrobial therapy.
Conclusion
The proposed changes to the CY 2025 Medicare Physician Fee Schedule are comprehensive, addressing various aspects of healthcare delivery and payment. These changes aim to improve healthcare quality, accessibility, and affordability for Medicare beneficiaries, reflecting the broader strategy of creating a more equitable healthcare system.