What’s Inside the CMS 2025 Proposed Physician Fee Schedule?

The Centers for Medicare & Medicaid Services (CMS) has released the proposed rule for its 2025 Medicare Physician Fee Schedule. 

According to the CMS press release, this year’s updates and new programs seek to expand whole-person care, recognizing a person’s wellbeing, including physical and behavioral health, as well as social determinants of health and support for caregivers.

If some of the new proposed programs come to fruition, they would expand the types of Medicare programs that provide support and revenue for many services providers already offer to some degree. 

ThoroughCare will continue to review and update our platform to ensure that crucial care coordination and Medicare-related programs are accessible and easy to implement.

Key highlights from the 2025 proposed rule

The CY 2025 Medicare Physician Fee Schedule (PFS) Proposed Rule outlines many vital changes and possible new programs, summarized below. 

These updates could present new programs and opportunities for providers to support comprehensive, reimbursable care for Medicare patients with chronic illnesses.

Physician payment adjustments

• Average payment rates under the PFS are proposed to be reduced by 2.93% in CY 2025 compared to CY 2024.
• The PFS conversion factor is proposed to be $32.36 in CY 2025, a decrease of $0.93 (or 2.80%) from CY 2024.

New programs and services

The following programs and updates could be most relevant to ThoroughCare clients and colleagues, including:

• Advanced Primary Care Management (APCM): This new set of services would be billable under three new HCPCS G-codes and incorporate elements of existing care management services, like Principal Care Management and Chronic Care Management. Physicians and non-physician practitioners (NPPs) using an advanced primary care model of care delivery would be eligible to bill for these services.
• Atherosclerotic Cardiovascular Disease (ASCVD) Risk Assessment and Management: Two new codes would cover an ASCVD risk assessment service and risk management services, incorporating lessons learned from the CMS Innovation Center's Million Hearts® Model.
• Caregiver Training Services (CTS): New coding and payment are proposed for caregiver training for direct care services and supports, as well as caregiver behavior management and modification training. These services could be furnished via telehealth.
• Behavioral Health Safety Planning Interventions: Separate coding and payment are proposed for safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose. This includes an add-on G-code billable with E/M visits or psychotherapy and a monthly billing code for post-discharge follow-up.
• Behavioral Health: Medicare payment is proposed for digital mental health treatment devices furnished incident to or integral to professional behavioral health services when used with ongoing behavioral health care treatment. Six new G codes are proposed for use by practitioners whose services are limited by statute to diagnosing and treating mental illness to mirror interprofessional consultation CPT codes.
• Opioid Treatment Programs (OTPs): Several telecommunications flexibilities are proposed, including making the current flexibility for furnishing periodic assessments via audio-only telecommunications permanent. Payment increases are proposed in response to recent regulatory reforms, and payment is proposed for new opioid agonist and antagonist medications approved by the FDA.
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Several changes are proposed to better align payments for care coordination services with other entities furnishing this care. RHCs and FQHCs would report the individual CPT and HCPCS codes that describe care coordination services rather than the single code G0511. Payment is proposed for non-behavioral health visits furnished via telecommunication technology. Several other changes are proposed, including a different payment rate for Intensive Outpatient Program services and updates to the FQHC market basket.
  
  
  

Telehealth expansions

There are several telehealth updates or expansions that may affect provider organizations, particularly those offering care management programs, including: 

• An interactive telecommunications system for telehealth services furnished in a beneficiary’s home may include two-way, real-time audio-only communication technology if the beneficiary is unable or unwilling to use video technology and the physician or practitioner is technically capable of providing video telehealth.
• Permanent adoption of a definition of direct supervision allows the physician or supervising practitioner to provide such supervision virtually through real-time audio and visual telecommunications. This includes services furnished incident to a physician’s service when auxiliary personnel employed by the physician provides those services.
• Permanent extension of the ability for teaching physicians to use virtual presence in teaching settings through December 31, 2025. CMS is also requesting information on potentially expanding the array of services included in the primary care exception.
• Several services were added to the Medicare Telehealth Services List provisionally, including demonstration before initiating home International Normalized Ratio (INR) monitoring and caregiver training services.
• Continuation of the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations.

60-day comment period: Let your voice be heard

Healthcare professionals and the general public have until Sept. 9, 2024, to submit comments (refer to file code CMS-1807-P) before this proposal is finalized. 

This article only details a few proposed changes to the 2025 Physician Fee Schedule. 

You can explore the full proposal in depth through CMS’s initial announcement, their Fee Schedule Fact Sheet, or the Medicare Shared Savings Program Fact Sheet.

ThoroughCare makes commenting easier

ThoroughCare will submit comments to CMS regarding the proposed changes, but we encourage anyone reading to do so, as well. If we can help make suggestions or provide relevant bullet points, or if you have any questions about how best to submit feedback, contact us.

ThoroughCare provides a comprehensive care coordination platform to proactively manage care and track and report services. Our software is intuitive and designed to meet CMS’s rules and requirements for various programs, including Chronic Care Management, Behavioral Health Integration, and Annual Wellness Visits. 

As CMS innovates, evolves, pivots Medicare coverage, and offers new programs, ThoroughCare provides the latest updates and features that meet the changing opportunities to deliver new patient services.