July 11, 2024
Last week, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the 2025 Medicare physician payment schedule. While PALTmed staff will analyze and develop a summary of the 2,000+ page proposal, we wanted to inform you of a handful of key issues.
CY 2025 Conversion Factor
The 2025 Medicare conversion factor is set to decrease for the fifth straight year by approximately 2.80 percent from $33.2875 to $32.3562. 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 (MACRA). Unfortunately, these cuts coincide with the ongoing growth in the cost of practicing medicine as CMS projects the increase in the Medicare Economic Index (MEI) for 2025 will be 3.6 percent.
Nursing Facility Codes
Home/Residence Visit Codes (Including Assisted Living)
Telehealth Services under the PFS
For CY 2025, CMS is proposing to continue the suspension of frequency limitations for subsequent nursing facility visits. 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.
Advanced Primary Care Management Services (APCM)
For CY 2025, CMS proposes to establish coding and pay under the PFS for a new set of APCM services described by three new HCPCS G-codes. The proposed APCM services would incorporate elements of several existing care management and communication technology-based services into a bundle that reflects the essential elements of delivering advanced primary care, including Principal Care Management, Transitional Care Management, and Chronic Care Management. The new APCM codes would be stratified into three levels based on the number of chronic conditions and enrollment as a Qualified Medicare Beneficiary, reflecting both patient medical and social complexity. This new proposed coding and payment makes use of lessons learned from the CMS Innovation Center's testing of a series of advanced primary care models, such as Comprehensive Primary Care Plus (CPC+) and Primary Care First (PCF), to inform the elements of APCM services and is intended to reduce the administrative burden associated with current coding and billing rules.
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 proposes to extend the date after which prescriptions written for a beneficiary in a long-term care (LTC) facility would be included in determining the CMS EPCS Program compliance from January 1, 2025, to January 1, 2028, and that related non-compliance actions would commence on or after January 1, 2028. EPCS improves prescriber workflow, thus reducing prescriber burden and increasing patient safety. CMS would be aligning CMS EPCS Program compliance calculations to the date by which the new NCPDP SCRIPT standard version 2023011, which includes three-way communication functionality that improves communication between pharmacies and LTC facilities, is required for prescribers when electronically transmitting prescriptions and prescription-related information for covered Part D drugs for Part D eligible individuals.
The text of the proposed rule can be accessed here.
Additional links include:
- CMS Press Release
- Physician Payment Schedule Fact Sheet
- Medicare Shared Savings Program Fact Sheet
- Quality Payment Program (QPP) Fact Sheet