9 important changes in the CY 2025 Medicare Physician Fee Schedule Final Rule
On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released its calendar year (CY) 2025 Medicare Physician Fee Schedule Final Rule, and with it comes a whole slew of changes. However, as with last year’s final rule, there’s good and bad news. The bad news is a highly anticipated payment cut. However, The final rule also includes several revenue opportunities that could improve the financial state of your medical practice.
In this blog, we’ll provide a physician fee schedule overview and cover nine important highlights of the rule and what medical practices need to know. [Note: You can download the CY 2025 Medicare Physician Fee Schedule Final Rule here. Additional files and supporting documentation are available for download here.]
Physician fee schedule overview: Physician payment cut starting January 1, 2025
CMS finalized a 2.8% physician payment cut to begin in January, and not surprisingly, publication of the CY 2025 Medicare Physician Fee Schedule Final Rule spurred backlash industry wide.
“To put it bluntly, Medicare plans to pay us less while costs go up,” said Bruce A. Scott, MD in a press release from the American Medical Association (AMA). “You don’t have to be an economist to know that is an unsustainable trend, though one that has been going on for decades. 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.”
Others echoed similar sentiments about the payment cut in the CY 2025 physician fee schedule.
“Today’s final rule throws the financial viability of physician practices into question and threatens beneficiary access to care,” said Anders Gilberg in a statement from the Medical Group Management Association (MGMA).
The AMA and MGMA are both urging Congress to pass a recently introduced House bill that would stop the physician fee schedule payment cuts. Stay tuned for new developments.
New HCPCS codes, payment for caregiver training
On a positive note, in the CY 2025 Medicare Physician Fee Schedule Final Rule, CMS finalized its proposal to establish new coding and payment for caregiver training for direct care services and supports. The goal? To help caregivers apply direct care strategies and techniques for individuals with an ongoing condition or illness to reduce complications. This includes, but is not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control.
The new codes are as follows:
G0541: Caregiver training in direct care strategies and techniques without the patient present, face-to-face, for an initial 30 minutes.
G0542: Caregiver training in direct care strategies and techniques without the patient present, face-to-face, for each additional 15 minutes. (Use G0542 in conjunction with G0541).
G0543: Group caregiver training in direct care strategies and techniques without the patient present, face-to-face, with multiple sets of caregivers.
Note that these codes have been added to the Medicare Telehealth Services list for CY 2025 on a provisional basis.
Expanded payment for E/M visit complexity add-on code
Starting January 1, 2025, CMS will also pay for evaluation and management (E/M) visit complexity add-on code G2211 when the same provider performs it on the same day as an annual wellness visit, vaccine administration, or any Medicare Part B preventive service. Of course, the provider must also always report a base E/M code (99202-99205 or 99211-99215) in addition to the complexity add-on code.
Want to learn more about G2211? View this CMS resource that includes helpful billing scenarios and documentation requirements that can help your medical practice promote compliance.
Telehealth flexibility remains unclear
While CMS will maintain limited telehealth flexibility where possible, most pre-pandemic rules will return unless there is legislative intervention. Here’s a quick physician fee schedule overview of the telehealth changes outlined in the CY 2025 Medicare Physician Fee Schedule Final Rule.
New HCPCS codes, payment for advanced primary care management services
Starting January 1, physicians can report three new HCPCS codes that reflect a new primary care model allowing providers to use virtual care and other technology to address patient care needs:
G0556: Level 1, for persons with one chronic condition
G0557: Level 2, for persons with two or more chronic conditions
G0558: Level 3, for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary
Here’s a helpful physician fee schedule overview of these codes and how providers can satisfy requirements for billing.
New HCPCS codes, payment for cardiovascular risk assessment and management
Beginning with CY 2025, CMS is finalizing coding and payment for an atherosclerotic cardiovascular disease (ASCVD) risk assessment service and risk management services. Providers must perform the ASCVD risk assessment with an E/M visit when they identify a patient at risk for CVD who does not have a diagnosis of CVD.
These are the two new relevant HCPCS codes added to the physician fee schedule:
G0537: Administration of a standardized, evidence-based ASCVD risk assessment for patients with ASCVD risk factors, 5-15 minutes, not more often than every 12 months per practitioner
G0538: ASCVD risk management services with the following required elements:
Patient is without a current diagnosis of ASCVD, but is determined to be at intermediate, medium, or high risk for CVD as previously determined by the ASCVD risk assessment
ASCVD-specific care plan established, implemented, revised, or monitored that addresses risk factors and risk enhancers and must incorporate shared decision making between the practitioner and the patient
Clinical staff time directed by physician or other qualified health care professional; per calendar month
These new codes are important because they may help physicians detect and prevent CVD. Be sure to read more about them in the CY 2025 Medicare Physician Fee Schedule Final Rule.
New HCPCS codes, payment for behavioral health services
For CY 2025, CMS is also finalizing separate coding and payment for safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose. The agency is also finalizing payment for a furnishing post-discharge follow-up for discharges from an emergency department for a crisis encounter.
These are the two new relevant HCPCS codes:
G0544: Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or another crisis encounter, per calendar month
G0560: Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan:
Recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies
Utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use
Utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis
Contacting mental health or substance use disorder professionals or agencies
Making the environment safe
These are important changes and potential revenue opportunities for mental health providers. Take the time to review the CY 2025 Medicare Physician Fee Schedule Final Rule for more information.
Expanded colorectal cancer screening
In CY 2025, CMS is expanding coverage of colorectal cancer (CRC) screening to include computed tomography colonography. The agency is also adding Medicare covered blood-based biomarker CRC screening tests to the continuum of screening. In addition, there will be no CRC screening frequency limitations to follow-up screening colonoscopy in the context of complete CRC screening.
These physician fee schedule changes can help medical practices promote access and remove barriers for cancer prevention and early detection particularly within rural communities and communities of color that experience higher rates of CRC.
Expanded coverage for the hepatitis B vaccine
In CY 2025, CMS is also expanding coverage of the hepatitis B vaccine to include individuals who haven’t previously received a completed hepatitis B vaccine series or whose vaccine history is unknown. In addition, a physician’s order will no longer be required for administering the hepatitis B vaccine. That’s surely good news for all medical practices looking to streamline efficiency.
Looking ahead: CY 2025 physician fee schedule
The CY 2025 Medicare Physician Fee Schedule Final Rule includes many other changes related to opioid treatment programs, dental and oral health, the ‘drugs covered as additional preventive services’ fee schedule, and more. Take the time to review the rule and ensure your medical practice’s electronic medical record vendor is on the same page. Know that edgeMED has you covered.
