Medicare Compliance & Reimbursement

Stay ahead of numerous telehealth revisions.

On Nov. 5, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for calendar year (CY) 2025. As always, the 3,088-page document was a mixed bag for everyone involved in healthcare. Here are some of the most important policy decisions that may affect you and your practice, positively and negatively, in the New Year.

Know What Will Happen to Your Bottom Line

The main lowlight of the 2025 MPFS will be its effect on your bottom line, as once again, CMS has chosen to retain the payment reduction CMS proposed in July and lower the conversion factor (CF) to 32.35. This includes a 0.02 percent positive budget neutrality adjustment, a 0.00 percent update adjustment factor, and the removal of the temporary 2.9 percent payment increase provided in the Consolidated Appropriations Act, 2024, in effect from March 9 to Dec. 31, 2024.

As a reminder, the CF is the final multiplier in the complicated formula known as the resource-based relative value scale (RBRVS), by which CMS calculates its payments for services and procedures. The RBRVS is comprised of three relative value unit (RVU) components: work (w), practice expense (pe) and malpractice insurance (mp). Each component is then multiplied by geographic practice cost indices (GPCI), added together, then multiplied again by the CF to produce a dollar value for each service or procedure: [(wRVU x wGPCI) + (peRVU x peGPCI) + (mpRVU x mpGPCI)] x CF.

If Congress fails to stop the cut from taking effect, physician reimbursement will decline 2.83 percent while costs continue to climb. Time will tell whether the current administration will act or leave this for the incoming administration. In the end, it is the patients who pay for physicians’ reimbursement shortcomings, generally the way of access to care.

View the Winners and Losers

The estimated impact on specialties ranges widely. Behavioral health looks to reap the biggest benefit, with clinical psychologists and clinical social workers possibly looking to receive 3 and 4 percent increases in both facility and nonfacility payments, respectively. Meanwhile, interventional radiology and ophthalmology specialties may be looking at lowered bottom lines in 2025, with interventional radiology receiving a 3 percent nonfacility reduction but a 1 percent facility increase — a 2 percent overall reduction — and ophthalmology receiving 2 percent nonfacility and 1 percent facility reductions — also a 2 percent overall reduction.

But the financial impact of the 2025 MPFS will be felt across the board. As Bruce A. Scott, MD, AMA president, put it in a November 1 >press release: “For physician practices operating on small margins already, this means it is harder to acquire new equipment, harder to retain staff, harder to take on new Medicare patients, and harder to keep the doors open, particularly in rural and underserved areas.”

Watch CMS Implement These Part B Policy Changes

As so often happens, CMS has balanced the bad financial news with a lot of coverage expansion, increased payments for select services, and new policy initiatives. Among the most significant changes are:

• Introduction of Advanced Primary Care Management Services (APCM): These services will be comprised of an initiating visit, “24/7 access and continuity of care, comprehensive care management, patient-centered comprehensive care plan, management of care transitions, care coordination, enhanced communication, population-level management, and performance measurement,” according to the CY 2025 MPFS Final Rule fact sheet.

To document the services, you’ll use new HCPCS codes G0556 (Advanced primary care management services provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month …), G0557 (Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline …), and G0558 (Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months …).

• Allowing payment for G2211: CMS is now going to pay for G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition …) “when the O/O E/M base code (CPT 99202-99205, 99211-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …]) is reported by the same practitioner on the same day as an AWV [annual wellness visit], vaccine administration, or any Medicare Part B preventive service.”
• Introduction of G0560: CMS is introducing a new HCPCS code, G0560 (Safety planning interventions, including assisting the patient in the identification of … personalized elements of a safety plan … (List separately in addition to an E/M visit or psychotherapy)), which describes “safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose,” per the PFS Fact Sheet.

Dial in These Telehealth Service Revisions

Dec. 31, 2024, sees the end of the COVID-19 public health emergency (PHE) telehealth waivers extended in the Consolidated Appropriations Act of 2023. This means the following changes will take effect on Jan. 1, 2025:

• CMS acknowledges the CPT^® Editorial Panel’s decision to delete audio-only telephone services CPT^® codes 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional …)
• Medicare will not recognize CPT^® telehealth codes 98000-98003 (Synchronous audio-video visit for the evaluation and management of a new patient …), 98004-98007 (Synchronous audio-video visit for the evaluation and management of an established patient …), 98008-98011 (Synchronous audio-only visit for the evaluation and management of a new patient …), or 98012-98015 (Synchronous audio-only visit for the evaluation and management of an established patient …)
• Medicare will pay separately for 98016 (Brief communication technology-based service (eg, virtual check-in) … provided to an established patient …) in lieu of HCPCS Level II code G2012 (Brief communication technology-based service (eg, virtual check-in) … provided to an established patient …), which CMS is deleting due to redundancy.
• Place of service (POS) codes will continue to have two telehealth designations:
  • 02 (Patient not in their home when telehealth services are rendered)
  • 10 (Patient in their home when telehealth services are rendered). POS 10 will continue to be paid at the non-facility rate

• CMS will continue to allow physicians to list their practice address, rather than their home address, when performing Medicare services via telehealth from their homes.
• CMS will reinstate pre-pandemic geographic and location restrictions for telehealth (before March 1, 2020). This means to receive telehealth services, Medicare patients must live in a health professional shortage area, a rural census track, or a county outside of a metropolitan statistical area at the time of service. Otherwise, they will not be covered.

Remember: Also in the final rule are payment and policy updates to the Medicare Shared Savings Program and Quality Payment Program, rural health clinics and federally qualified health clinics, the ambulance fee schedule for prehospital blood transfusion, and the Clinical Laboratory Fee Schedule. CMS also addresses code valuations and misvalued codes in the CY 2025 PFS final rule as usual.

For more information, read the full text of the PFS final rule for calendar year (CY) 2025.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
Renee Dustman, Managing Editor, AAPC
Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM, PACS,
Healthcare Coding and Reimbursement Consultant in Laguna Niguel, California