What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2025 physician fee schedule (PFS) proposed rule.
What else to know: The proposed CY 2025 PFS conversion factor is $32.36, a decrease of $0.93, or 2.8%, from CY 2024.
Key provisions of the rule include:
- Evaluation and Management (E/M) Codes: CMS suggests creating a new advanced primary care management bundle to support coordination of care and improve outcomes for patients with chronic conditions.
- Telehealth: CMS wants to extend certain telehealth flexibilities through Dec. 31, 2025, including frequency limitations for subsequent care services in inpatient, nursing facility, and critical care consultations; reporting of practice addresses instead of home addresses when providers perform services from their home; billing of telehealth services by federally qualified health centers and rural health clinics; and virtual direct supervision policies. However, absent congressional action, other telehealth flexibilities including originating site and geographic restrictions will expire on Dec. 31.
- Behavioral Health Services: CMS introduces several provisions intended to advance payments and expand access to behavioral health services, including a new add-on code to be billed in conjunction with an E/M or psychotherapy service to account for safety planning activities for patients at increased risk for suicide or overdose. Other provisions include a new monthly code representing a bundle of services (including phone calls) for post-discharge follow-up with patients discharged from the emergency department for a crisis episode, new codes for FDA-cleared digital mental health treatment devices, and new codes to allow clinical psychologists, licensed social workers, marriage and family therapists, and mental health counselors to bill for interprofessional consultations with other practitioners.
- Overpayment Provisions: The rule proposes provisions to implement the Medicare parts A and B overpayment requirements of the Affordable Care Act.
- Payment for Dental Services for Dialysis Patients: CMS recommends payment for certain dental services for beneficiaries undergoing dialysis for end stage renal disease.
- Medicare Shared Savings Program (MSSP): Significant changes to the MSSP could include:
- Providing advanced payments for accountable care organizations (ACOs) with a track record of achieving savings to provide services not otherwise covered by Medicare and/or invest in staffing and infrastructure
- Implementing a health equity adjustment to the spending benchmark to account for the increased spending associated with caring for large populations of dually eligible beneficiaries or those eligible for the Part D low-income subsidy
- Removing fraudulent expenditures from an ACO’s actual spending and the benchmark
- Adding six new measures to the MSSP set and streamlining reporting options
A fact sheet specific to these policies is available on CMS’ website.
- Quality Payment Program (QPP): A detailed fact sheet on the QPP changes is available here.
Comments on the rule are due Sept. 9. A CMS fact sheet is available here. CHA is currently reviewing the rule and will provide a detailed summary.
