Conversion Factor
According to the proposed rule’s accompanying fact sheet issued by CMS, the average payment rates under the 2025 PFS would be reduced by 2.93 percent compared to the average amount these services are being paid for most of 2024. The change to the PFS conversion factor incorporates (a) the 0.00 percent overall update required by statute, (b) the expiration of the 2.93 percent increase in payment for 2024 required by statute, and (c) a relatively small estimated 0.05 percent adjustment necessary to account for changes in work relative value units (RVUs) for some services.
All told, the above factors translate to a proposed estimated 2025 PFS conversion factor of $32.36. This reflects a decrease of $0.93 (or 2.80 percent) from the current 2024 conversion factor of $33.29.
Evaluation and Management
The proposed rule authorizes payment of the office/outpatient evaluation and management (E/M) visit complexity add-on code G2211 when the underlying E/M code 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 furnished in the office or outpatient setting.
Telehealth Services
The following items are found in the CMS fact sheet relating to the 2025 PFS proposed rule:
- An interactive telecommunications system may include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site practitioner is technically capable of using an interactive telecommunications system but the patient is not capable of, or does not consent to, the use of video technology.
- CMS will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home.
- CMS adopts a definition of direct supervision that allows the supervising practitioner to provide such supervision through real-time audio and visual interactive technology. CMS will continue to define “immediate availability” to include real-time audio and visual interactive technology only through December 31, 2025.
- Teaching physicians are allowed to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings.
- Only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit, with the patient, resident and teaching physician—with all parties in separate locations) through December 31, 2025.
- This virtual presence will continue to meet the requirement that the teaching physician be present for the key portion of the service.
According to the American Society of Anesthesiologists (ASA), there will be new stand-alone codes reflecting certain telehealth services available to providers beginning in 2025. The ASA published the following statement:
[T]he CPT® Editorial Panel approved of a request to establish 16 new Category I E/M telemedicine codes for both new and established patients using audio-video or audio only technology. The Panel also approved one new Category I virtual check in code.
While these new telemedicine codes will be available and may be payable by some health plans, Medicare will not recognize them, as the below excerpt from the proposed rule indicates:
We do not believe that there is a programmatic need to recognize the audio/video and audio-only telemedicine E/M codes for payment under Medicare. We are proposing to assign CPT codes 9X075-9X090 a Procedure Status indicator of “I”, meaning that there is a more specific code that should be used for purposes of Medicare, which in this case would be the existing office/outpatient E/M codes currently on the Medicare telehealth services list when billed with the appropriate POS code to identify the location of the beneficiary and, when applicable, the appropriate modifier to identify the service as being furnished via audio-only communication technology.
However, CMS is proposing to pay for the new virtual check-in code (9X091). This code would replace the current HCPCS code G2012 and be considered a communication technology-based service that is not subject to the Medicare telehealth services requirements.
Before leaving this discussion of telehealth services, one final word is in order. The patient location of such services is changing. According to the proposed rule:
Under the current statute, the geographic location and site of service restrictions on Medicare telehealth services will once again take effect for services furnished beginning January 1, 2025. Although there are some important exceptions, including for behavioral health services and ESRD-related clinical assessments, most Medicare telehealth services will once again, in general, be available only to beneficiaries in rural areas and only when the patient is located in certain types of medical settings.
Based on our current understanding, this may mean that telehealth services where the patient is in their home will no longer be payable in most cases, though some exceptions will remain.
Opioid Treatment Programs
CMS is proposing several telecommunication technology flexibilities for opioid use disorder (OUD) treatment services furnished by Opioid Treatment Programs (OTPs), as long as the use of these technologies are permitted under the applicable SAMHSA and DEA requirements at the time the services are furnished and all other applicable requirements are met. Here are the details:
- Make permanent the current flexibility for furnishing periodic assessments via audio-only telecommunications beginning January 1, 2025 so long as all other applicable requirements are met.
- Allow the OTP intake add-on code to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with methadone (using HCPCS code G2076) if the OTP determines that an adequate evaluation of the patient can be accomplished via an audio-visual telehealth platform.
- Payment increases in response to recent regulatory reforms for OUD treatment finalized by SAMHSA at 42 CFR part 8. Specifically, CMS is proposing to update payment for intake activities furnished by OTPs to include payment for social determinants of health risk assessments to adequately reflect additional effort for OTPs to identify a patient’s unmet health-related social needs or the need and interest for harm reduction interventions and recovery support services that are critical to the treatment of an OUD.
- OTPs must append an OUD diagnosis code on claims for OUD treatment services, consistent with Medicare coverage and payment provisions under the Social Security Act.
In a future alert, we will bring you details arising from the proposed rule related to changes within the Quality Payment Program, including MIPS. If you have any questions about these topics, please contact your account executive.