What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2025 Medicare physician fee schedule (PFS) final rule, in which the final CY 2025 PFS conversion factor is $32.35 — a decrease of 2.8% from CY 2024.
What else to know: CMS published a fact sheet on the CY 2025 Medicare PFS that shares the rate setting and conversion factor, and much more.
Key provisions of the rule include:
- Telehealth: CMS will 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, 2024.
- Behavioral Health Services: CMS finalizes several provisions intended to advance payments and expand access to behavioral health services, including a new add-on billing code that accounts for safety planning activities in conjunction with an evaluation and management (E/M) or psychotherapy service 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 finalizes provisions to implement the Affordable Care Act’s Medicare parts A and B overpayment requirements; this includes suspending the 60-day deadline for reporting, as well as returning overpayments for up to 180 days to allow time for providers to investigate and calculate overpayments.
- Clinical Laboratory Fee Schedule (CLFS): CMS finalizes policies to delay laboratory private payer payment rate data and associated payment cuts under the CLFS. Since the proposed rule was released, Congress further delayed the data reporting deadline until March 31, 2026, and phased payment reductions to 0% for 2025 and 15% for each year from 2026 through 2028. CMS updates its final regulations to reflect these statutory changes.
- Medicare Shared Savings Program (MSSP): CMS finalized several changes to the MSSP, such as excluding suspected anomalous spending from financial calculations for the MSSP and revising the quality measure set while streamlining reporting options. CMS has made available a fact sheet specific to the MSSP policies.
- Quality Payment Program (QPP): CMS updates policies for the QPP, which includes two tracks — the Merit-based Incentive Payment System (MIPS) and alternative payment models. Key policies addressed in the final rule include five additional MIPS Value Pathways, revisions to the MIPS quality category, and modifications to the scoring methodology for the MIPS improvement activities category. CMS has issued a detailed fact sheet on the QPP changes.
CHA is currently reviewing the rule and will provide a detailed summary in the coming weeks.
