ED Coding and Reimbursement Alert

Big surprise: Another rate cut is coming.

The Centers for Medicare & Medicaid Services (CMS) proposed rule for the 2025 Medicare Physician Fee Schedule (MPFS) has dropped, and providers may not be excited about the news within.

The proposed rule, which will be published officially at the end of July, is 2,248 pages, and features strategies for improving care for specific health and social conditions, as well as adjustments to big-picture business aspects of providing medical care. The Biden-Harris administration says it’s committed to advancing health equity and supporting whole-person care.

“Whole-person care means moving towards a healthcare system that recognizes each unique aspect of a person and their wellbeing, including physical health, behavioral health, oral health, social determinants of health, and caregiving supports, and it all starts first with a foundation of primary care that can integrate these components,” said Meena Seshamani, MD, PhD, deputy CMS administrator and director of the Center for Medicare. “We are taking lessons learned from numerous CMS Innovation Center models to strengthen primary care teams and accountable care organizations, allowing them to better meet the unique needs of every person with Medicare.”

Prepare for These Framework Changes

One of the big takeaways is the change in rate: The average payment rates may be reduced by 2.93 percent compared to the average amount being paid in calendar year (CY) 2024. The proposed conversion factor for CY 2025 is $32.36, a decrease of $0.93 from CY 2024.

Otherwise, CMS is hoping to strengthen primary care, as well as focusing on quality improvement and innovation. After testing some value-based primary care models via the CMS Innovation Center, CMS plans to establish an advanced primary care bundle via a multiyear effort, which will involve earmarking certain primary care services and making adjustments for patient medical and social complexity. These services would be tied to primary care quality measures.

According to the proposed rule, CMS will lean on quality measures elsewhere, too, including establishing six new Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) for ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. CMS is continuing its development of the MVP program and, in the meantime, updating MIPS scoring methodologies and measure inventories, allowing eligible clinicians to participate in MIPS as CMS transitions to MVPs.

Know About Expanded Access Opportunities

In support of the Biden-Harris administration’s aims to transform how the country addresses behavioral healthcare, CMS is proposing new payments for providers caring for people at high risk of suicide or overdose, with separate payments for safety planning interventions and follow-ups after discharge. There may also be new payment and coding options for behavioral health specialist consultations, as well as for digital tools that enable specific behavioral health treatments.

CMS is also proposing to bolster coverage of some dental services that affect the success of certain medical care services, like organ transplants, cardiac valve replacements, valvuloplasty procedures, head and neck cancers, chemotherapy, chimeric antigen receptor T- (CAR-T) cell therapy, and high-dose bone modifying agents (antiresorptive therapy), as well as dialysis treatments for end-stage renal disease, some diabetes care, and some immunosuppressive therapies.

In addition, CMS is proposing new payment for caregiver training services, including virtual options, that are related to direct care services and support.

Understand Evolution of Telehealth Flexibilities

During the COVID-19 public health emergency (PHE), CMS produced some waivers that expanded access to telehealth services. Many such flexibilities, which were extended temporarily, are set to expire at the end of 2024. CMS is proposing to continue to permit some practitioners to virtually supervise auxiliary personnel. CMS is also proposing that practitioners will be able to use their enrolled practice location instead of their home address when providing telehealth services from their home.

However, CMS warns that the statutory restrictions on geography, site of service, and practitioner type in place before the COVID-19 PHE will go back into effect Jan. 1, 2025, unless Congress acts. The agency says they’ll be requesting information to consider whether and how to expand services under the primary care exception umbrella in future rules.

You may recall that in the CY 2024 rule, CMS created a new “provisional category” along with a permanent category and established criteria for codes to be added to each category. CMS added all five ED evaluation and management codes (99281-99285), critical care codes, and observation codes on the approved telehealth list through at least December 31, 2024.

In this new proposed rule for 2025, CMS does not propose any changes to current provisional codes, effectively keeping these ED codes on the provisional list for at least one more year.

Note These Nitty-Gritty Condition Care Aspects

CMS is hoping to improve global surgery payment accuracy via practitioners reporting transfer of care modifiers in all transfer of care scenarios. The agency believes that this would provide them with more data about how practitioners furnish global surgical packages and thus allow CMS to make more accurate payments. CMS is proposing a new add-on code, GPOC1, for postoperative care services provided by practitioners not involved in the actual surgical procedure.

The agency is also hoping to hone its atherosclerotic cardiovascular disease (ASCVD) risk assessment and risk management services by proposing coding and payment options for risk assessments provided during an evaluation and management (E/M) visit for patients who may be at risk of CVD but do not yet have a diagnosis. The risk assessment could be conducted via a standardized, evidence-based assessment tool including demographic data; modifiable risk factors; history of tobacco, alcohol, and other drug use; and laboratory data; and would result in a provider’s 10-year estimate of the patient’s risk.

Beware Grim Realities

If this rule is finalized, it will mark the fifth consecutive year that CMS has reduced its payments. Meanwhile, predictions about the Medicare Economic Index (MEI), which is a measure of practice cost inflation, show it may increase by 3.6 percent, further widening the gap between the cost of delivering care versus Medicare payments for that care.

“Physician practices cannot continue to absorb rising costs while their payment rates dwindle. The Medicare Physician Payment Advisory Commission (MedPAC) and the Medicare Trustees have issued warnings about the dangers of repeated Medicare cuts and how they threaten access to care. As one of the only Medicare providers without an inflationary payment update, physicians have waited patiently for this change. Medicare physician payment declined 29% from 2001 to 2024, adjusted for inflation,” said Bruce A. Scott, MD, president of the AMA, in a release about the proposed rule.

You can read the entire proposed rule and submit public comment through September 9.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor III, AAPC