2025 Physician Fee Schedule Final Rule Released

The Centers for Medicare & Medicaid Services (CMS) has issued the final rule for the Medicare Physician Payment Schedule for Calendar Year (CY) 2025. The staff at the Post-Acute and Long-Term Care Medical Association will review the more than 3,000-page rule and prepare a summary. In the meantime, we wanted to highlight a few key issues for you.

The 2025 Medicare conversion factor will decrease for the fifth straight year by approximately 2.83 percent from $33.2875 to $32.3465. This cut is largely the result of the expiration of a 2.93 percent temporary update to the conversion factor at the end of 2024 and a 0 percent baseline update for 2025 under the Medicare Access and CHIP Reauthorization Act. Unfortunately, these cuts coincide with the ongoing growth in the cost to practice medicine as CMS projects the increase in the Medicare Economic Index (MEI) for 2025 will be 3.5 percent.  

Calculation of the CY 2025 PFS Conversion Factor

These are the estimated values for the nursing facility codes in CY 2025:

These are the proposed values for the Home/Residence Visit Codes (Including Assisted Living):

Telehealth Services

For CY 2025, CMS is finalizing its delay to suspend the frequency limitations for subsequent nursing facility visits (99307-99310) through CY 2025. CMS indicated that by pausing the frequency limitations, they will gather an additional year of data to determine how practice patterns are evolving and what changes, if any, to frequency imitations should be made. 

CMS is proposing to add several services to the Medicare Telehealth Services List on a provisional basis, including demonstration before initiation of home International Normalized Ratio (INR) monitoring and caregiver training services. CMS is proposing that beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.

Caregiver Training Services (CTS)

For CY 2025, CMS is finalizing its proposal to establish new coding and payment for caregiver training related to direct care services and supports. The training topics may include, but are not limited to, techniques for preventing decubitus ulcer formation, wound care, and infection control. CMS is also finalizing a proposal to create new coding and payment for caregiver behavior management and modification training, which can be provided to the caregiver(s) of an individual patient. Additionally, CMS is finalizing a policy to allow these training sessions to be conducted via telehealth.

Advanced Primary Care Management Services (APCM)

The Department of Health and Human Services is establishing coding and payment for advanced primary care management services in the CY 2025 PFS final rule.

For CY 2025, CMS is finalizing new coding and payment under the PFS for APCM services, identified by three new HCPCS G-codes (G0556, G0557, G0558). These services combine elements from existing care management and technology-based services without time-based thresholds, thereby reducing administrative burdens. The new APCM codes are tiered based on the patient's number of chronic conditions and status as a Qualified Medicare Beneficiary:

• Level 1 (G0556): One chronic condition
• Level 2 (G0557): Two or more chronic conditions
• Level 3 (G0558): Two or more chronic conditions and Qualified Medicare Beneficiary status

This coding and payment structure reflects insights from previous CMS Innovation Center models, like Comprehensive Primary Care Plus (CPC+) and Primary Care First (PCF). Requirements include consent, an initiating visit, 24/7 access, comprehensive care management, and more. For MIPS eligible clinicians, performance management can be reported through the Value in Primary Care MIPS Value Pathway, starting in 2026.

CMS has received numerous comments suggesting increased valuation for these codes and will reconsider this in future rulemaking. However, CMS is finalizing an increase for Level 1 (G0556) starting January 1, 2025. Physicians and non-physician practitioners using an advanced primary care model can bill for these services, which aim to better recognize advanced primary care, simplify billing, and support long-term relationships between providers and patients. Participants in specific ACO programs can meet the requirements for these codes through their existing model participation.

Electronic Prescribing for Controlled Substances (EPCS) for a Covered Part D Drug Under a Prescription Drug Plan or a Medicare Advantage Prescription Drug Plan

CMS is finalizing its proposal to extend the date after which prescriptions written for beneficiaries in long-term care (LTC) facilities will be included in the CMS EPCS Program compliance assessments, moving it from January 1, 2025, to January 1, 2028. Related non-compliance actions will begin on or after January 1, 2028. EPCS enhances prescriber workflow, reducing burden and increasing patient safety. CMS is aligning EPCS Program compliance calculations with the implementation date of the new NCPDP SCRIPT standard version 2023011, which introduces three-way communication functionality to improve interactions between pharmacies and LTC facilities when electronically transmitting prescriptions and prescription-related information for covered Part D drugs.