Additional Details
Payment Updates
- RBRVS Conversion Factor Reduction: For CY 2025, CMS is proposing a conversion factor of $32.36, a decrease of $0.93, or 2.80%, from the current CY 2024 conversion factor of $33.29.
- This update reflects the expiration of the 2.93% statutory payment increase for CY 2024, a 0.0% statutory update factor required under the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), and a 0.5% RVU budget-neutrality adjustment.
- Compared to prior years, the CY 2025 proposed rule does not include the same significant redistribution of RVU dollars across specialties. In contrast, expiration of the statutory payment increases is expected to result in a net decrease across most specialties.
- Time-Based Anesthesia Conversion Factor Reduction: CMS estimates the CY 2025 time-based anesthesia conversion factor to be $20.33, which represents a decrease of 2.1% from the 2024 rate of $20.77.
Coding Updates
- Office/Outpatient (O/O) and Evaluation and Management (E/M) Visits:For CY 2025, CMS is proposing to allow payment of the O/O and E/M visit complexity add-on code G2211 when the base code is reported by the same practitioner on the same day as annual well visits, vaccine administration, or any Medicare Part B preventive service furnished in the office or outpatient setting.
- Payment for the separately payable G2211 visit complexity add-on code was finalized in the CY 2024 PFS final rule. This add-on code is intended to reimburse for the time, intensity, and PE resources involved to establish longitudinal relationships with all patients and to address most healthcare needs with consistency and continuity over longer periods of time.
- Coding for Caregiver Training: CMS is proposing to establish new coding and payment for caregiver training, including but not limited to techniques to prevent decubitus ulcer formation, wound dressing changes, infection control, and medication administration. CMS is also proposing to allow the proposed CTS to be furnished via telehealth.
- Advanced Primary Care Management Services (APCM): For CY 2025, CMS is proposing to establish coding payment under the PFS for a new set of APCM services through three new HCPCS G codes. The proposed services include elements of advanced primary care such as principal care management, transitional care management, and chronic care management.
- CMS is proposing that for CY 2025, physicians and nonphysician practitioners could bill for APCM services when they are the continuing focal point for needed service and responsible for the patient’s primary care.
- Cardiovascular Risk Assessment and Management: For CY 2025, CMS is proposing coding and payment for atherosclerotic cardiovascular disease (ASCVD) risk assessment service and risk management services.
- The proposed risk assessment would be completed in conjunction with an E/M visit when a risk for cardiovascular disease (CVD) is identified for a patient who is not currently diagnosed with CVD.
- The proposed risk management service would include service elements related to CVD risk reduction (aspirin, blood pressure management, cholesterol management, smoking cessation) for beneficiaries at medium or high risk (>15% in the next 10 years) for CVD.
- Add-On for Infectious Diseases: For CY 2025, CMS is proposing a new HCPCS add-on code to describe intensity and complexity for hospital inpatient or observation care associated with confirmed or suspected infectious disease performed by a physician with specialized training in infectious disease.
Extension of Telehealth Provisions
- For CY 2025, CMS is proposing several modifications and expansions to the use of telehealth services, including the following:
- Proposal to add several services to the Medicare Telehealth Services List, including demonstration prior to initiation of home international normalized ratio (INR) monitoring and caregiver training.
- Proposal to continue the suspension of the frequency limitations for subsequent inpatient visits, nursing facility visits, and critical care consultations.
- Proposal to approve use of two-way, real-time, audio-only communication if the physician or practitioner is technically capable of using an interactive telecommunications system but the patient is not capable of, or does not consent to, use of video.
- Proposal to permanently adopt a definition for direct supervision that allows the physician or supervising practitioner to provide supervision through real-time audio and visual interactive telecommunications, for a select subset of services. For all other services, CMS is proposing to continue defining “immediate availability” to include real-time audio and visual interactive telecommunications technology through December 31, 2025.
Access to Behavioral Health
- For CY 2025, CMS is proposing several changes to expand use and adoption of behavioral health services, including:
- Proposal to establish coding and payment for safety planning interventions for patients in crisis through creation of an add-on G code that would be billed along with an E/M visit or psychotherapy service.
- Proposal to establish a monthly billing code for follow-up services performed in conjunction with discharge from the emergency room for a crisis encounter. Specific protocols would be required post-discharge, including four calls a month.
- Proposal to establish Medicare payment for digital mental health treatment devices through creation of three new HCPCS codes.
Finally, CMS is seeking comment on whether coding and payment for Intensive Outpatient Program (IOP) services would be appropriate in additional settings of care, such as Certified Community Behavioral Health Clinics. CMS is also seeking comment on facilities that offer crisis stabilization and nonemergent urgent care.
Other Updates
- Ambulatory Specialty Care Model Request for Information: CMS is issuing a request for information on the design of a potential ambulatory specialty care model that would be based on the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) with an aim to increase engagement of specialists in value-based care and expand incentives.
- Supervision for Physical Therapists (PTs) and Occupational Therapists (OTs) in Private Practice: CMS is proposing to allow general supervision of physician therapy assistants (PTAs) and occupational therapy assistants (OTAs) by PTs and OTs in private practice. This will align with general supervision guidelines for PTs and OTs who work in institutional settings.
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Edited by: Matt Maslin
Published July 16, 2024
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