The 2025 CMS PFS final rule is set to impact healthcare providers. Learn about the reimbursement changes and how they might affect your practice.
On November 1, the Centers for Medicare & Medicaid Services announced the final rule for the 2025 physician fee schedule. This rule will reduce the conversion factor by 2.8%, bringing it down to $32.35 in 2025 from $33.29 in 2024, a decision that has stirred significant concern among healthcare providers.
Several key factors have contributed to the reduction in physician payments for 2025. Firstly, the statutory requirement for a 0% overall update has a significant impact. Additionally, the expiration of a temporary 2.93% payment boost that was in place for 2024 means that this increase will no longer apply. Moreover, a minor adjustment of 0.02% has been made to account for changes in work relative value units (RVUs), which measure the value of services provided. Collectively, these factors culminate in a lower conversion factor for 2025, impacting the reimbursement rates for physicians.
Here are some of the reimbursement changes outlined in the Medicare Physician Fee Schedule (PFS) final rule.
Office/Outpatient (O/O) Evaluation and Management (E/M) Visits
For CY 2025, CMS will allow payment of the office/outpatient (O/O) evaluation and management (E/M) visit complexity add-on code G2211 when the O/O E/M base code (CPT codes 99202-99205, 99211-99215) is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service, including the Initial Preventive Physical Examination (IPPE), in the office or outpatient setting.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
CMS is finalizing changes to align RHC and FQHC payments for care coordination services with other entities. Starting in 2025, RHCs and FQHCs will report individual CPT and HCPCS codes instead of HCPCS code G0511, with a six-month transition period until July 1, 2025, to update billing systems. This change allows billing of add-on codes, improving payment accuracy and service transparency. Payments will be based on national, non-facility PFS amounts, in addition to the RHC AIR or FQHC PPS, and updated annually. RHCs and FQHCs are not required to report the Value in Primary Care MVP.
Telehealth
Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services. CMS extended telehealth waivers through 2025, allowing practice address reporting instead of home addresses, billing for telehealth by Federally Qualified Healthcare Centers and Rural Health Clinics, and virtual supervision for residents. The definition of interactive telecommunications now includes two-way, audio-only communication for Medicare telehealth if video is not possible.
Behavioral Health Services
CMS finalized separate coding and payment for safety planning interventions for patients in crisis. Payment for a G-code will be available in 20-minute increments for interventions by the billing practitioner. Additionally, a monthly billing code will cover post-discharge follow-up contacts, bundled as four calls per month.
To enhance psychotherapy access, CMS, in collaboration with the FDA, is finalizing Medicare payments for digital mental health devices. These devices, cleared under section 510(k) or granted de novo authorization, will be used alongside behavioral health care. CMS is introducing three new HCPCS codes and six G codes for billing by mental health professionals, aligning with current consultation CPT codes.
Potential Impacts on Healthcare Providers
The reduction in physician payments is likely to have several repercussions for healthcare providers. For many, this could mean tighter budgets and increased pressure to manage costs effectively while still providing high-quality care. Smaller practices, in particular, may feel the financial strain more acutely.
Furthermore, there may be broader implications for patient care. Providers might face challenges in maintaining the same level of service, potentially affecting patient access to care and overall health outcomes. The reduction could also influence the dynamics of physician recruitment and retention, as financial incentives play a crucial role in these areas.
To mitigate the impact of the payment reduction, healthcare providers can explore several strategies. Enhancing operational efficiency is critical; this could involve adopting more advanced healthcare technologies, optimizing workflow processes, and reducing administrative burdens.
Dealing with reimbursement challenges can be overwhelming. Quadax is here to help. If you are in need of a dependable partner to help spot opportunities, simplify processes for maximum revenue results, reduce your stress, and effectively handle the complexities of the patient experience, request a strategy call with one of our revenue cycle experts.
