On July 10, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule (2025 PFS Proposed Rule), which contains proposals to update PFS payment rates, improve payment for and access to behavioral health services, extended telehealth flexibilities, establish ways to enhance access to primary care services, and strengthen the Medicare Shared Savings Program (MSSP).

Key Takeaways

• The CY 2025 PFS Proposed Rule continues efforts by the Biden-Harris Administration to strengthen access to primary and behavioral health care by establishing new codes and payments and adding services to help beneficiaries and practitioners to safely administer and receive care in their own home.
• CMS put out several press releases and fact sheets to inform the public on these changes. The complete proposed rule can be found in the Federal Register here.

The CY 2025 PFS Proposed Rule includes the following proposals:

• Updates to the PFS payment rates: CMS is proposing to lower PFS payment rates by 2.93% in 2025 compared to payment rates in 2024. In dollars, this change amounts to a conversion factor of $32.36 which is a decrease of $0.93 from the CY 2024 conversion factor of $33.29.
• New codes for Caregiver Training Services (CTS): CMS would like to establish new coding and payment for caregiver training for direct care services and for caregiver behavior management and medication training. Topics of training can include techniques to prevent decubitus ulcer formation, wound dressing changes, infection control, special diet preparation, and medication administration. CMS is also proposing to allow the training services to be provided to caregivers via telehealth.
• Services addressing Health-Related Social Needs (HRSNs): CMS is issuing a broad Request for Information (RFI) on the Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment to engage the public on how the agency can refine the program for future rulemaking. CMS is specifically requesting comments on other types of auxiliary personnel (including clinical social workers); other certification/training requirements that are not captured in current coding and payment for these services; how codes are furnished in conjunction with community-based organizations; and how to improve utilization in rural areas.
• Updates to Telehealth Services:  Starting in January 1, 2025, CMS is proposing a telecommunications system that can include two-way, real-time audio-only communication technology for any telehealth service provided to a beneficiary in their home if the beneficiary is incapable of or does not consent to using video. In addition, this proposed rule will continue to allow distant site practitioners to use their currently enrolled practice location instead of their home address when they provide telehealth services from their home. CMS is also proposing to permanently adopt a definition of “direct supervision” that allows physicians or supervising practitioners to provide said supervision through-real time audio and visual interactive telecommunications. Lastly, for billing purposes, CMS is proposing to continue their current policy that allows for teaching physicians to administer care virtually when residents are involved in all teaching settings. For example, a three-way telehealth visit with the patient, resident, and teaching physician all in separate locations.
• New codes for Advanced Primary Care Management Services (APCM): The 2025 PFS Proposed Rule establishes three new HCPCS G-codes and payments for a new set of APCM services. These new services incorporate elements of existing care management and communication technology-based services into a bundle of services including Principal Care Management, Transitional Care Management, and Chronic Care Management. Beginning January 1, 2025, CMS is proposing that physicians and non-physician practitioners (NPPs) who use an advanced model of care delivery can bill for APCM services as long as they are responsible for their patient’s primary care needs. CMS is proposing a performance measurement requirement as a condition of payment for APCM services called the Value in Primary Care MIPS Value Pathway (MVP) which was developed to include clinical quality measures that are foundational to primary care.
• Updates to Behavioral Health Services: CMS is proposing several updates for behavioral health services. To increase access to psychotherapy, the agency is proposing to use Medicare payment for digital mental health treatment devices used in both professional behavioral health services and ongoing behavioral health care treatment within a behavioral health treatment plan of care. CMS is also proposing to establish separate coding and payment for safety planning interventions for patients in crisis including those with suicidal ideation or at risk of suicide or overdose. More specifically, CMS will create an add-on G code that would be billed with an E/M visit or psychotherapy service when practitioners personally provide safety planning interventions. Additionally, CMS will create codes for the following services:
  • Three new HCPCS codes to monitor how digital mental health treatment devices are used as a part of overall behavioral health care;
  • Six G codes to mirror current interprofessional consultation CPT codes for practitioners in specialties whose covered services are limited by statute to services for the diagnosis and treatment of mental illness (including Clinical Psychologists, Clinical Social Workers, Marriage and Family Therapists, and Mental Health Counselors);
  • A monthly billing code that requires specific protocols in furnishing post-discharge follow-up contacts that are performed in conjunction with a discharge from the emergency department for a crisis encounter, as a bundled service describing four calls in a month.
• Changes in coverage for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): CMS is proposing to make a significant change for RHCs and FQHCs for primary care services. CMS will require that RHCs and FQHCs to explicitly provide primary care services instead of being “primarily engaged” in providing these services as indicated in sub-regulatory guidance. This new rule will not stop RHCs or FQHCs from continuing to provide specialty care, but it will encourage RHCs and FQHCs especially in rural areas to provide primary care services in those communities.
• Changes to the Medicare Shared Savings Program (MSSP): CMS proposes establishing a new “prepaid shared savings” option which will help ACOs that have a history of earning shared savings an advance of savings which they use to make investments that would aid beneficiaries such as investments in direct beneficiary service, staffing, and investments to improve care coordination. CMS is also proposing a new quality measure set called the Alternative Payment Model (APM) Performance Pathway (APP) Plus Quality Measure Set to move towards the Universal Foundation of quality measures and to better align with the quality measures reported by Shared Savings Program ACOs with the Medicaid Core Sets, the Marketplace Quality Rating System, and Medicare Advantage and Part D Star Ratings. In the PFS proposed rule, CMS also proposes to further incentivize ACOs that serve members in rural and underserved communities by adopting a health equity benchmark adjustment similar to the one in the ACO REACH Model, which has been associated with increased safety net provider participation. Lastly to improve financial calculations within the program, CMS is proposing a calculation methodology to address the impact of improper payments in recalculating expenditures and payment amounts used in Shared Savings Program financial calculations upon reopening a payment determination.

Conclusion

Public comments on the Medicare PFS Proposed Rule closes on September 9, 2024 and is expected to be finalized by November 1, 2024. If finalized, these rules will take effect on January 1, 2025. To learn more about recent federal proposed rules such as the CY 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule (CY 2025 OPPS/ASC Proposed Rule), visit our blog or contact the professionals listed below.