Initial feedback shows that industry groups don't expect CMS to alter its plan for conversion factor cuts. AMGA, which represents multispecialty medical groups, said that it "expects CMS will finalize this proposed cut in the conversion factor, meaning Congress must act to prevent it from taking effect," according to a July 10 statement.
Many telehealth flexibilities poised to come to a halt
CMS will maintain some telehealth flexibilities, but extension or permanent implementation of the main waivers is up to Congress. The agency intends to expand the audio-only telehealth option to any patient who is at home during the service “if the distant site physician or practitioner is technically capable of using an interactive telecommunications system as defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication, but the patient is not capable of, or does not consent to, the use of video technology,” CMS writes in the proposed rule.
Under current Medicare rules, the audio-only exception would be limited to encounters related to behavioral health care if the COVID-19 public health emergency (PHE) waivers were not in effect. CMS also plans to keep looser direct supervision requirements for audio-visual telehealth services in certain circumstances through 2025 and will allow providers who perform telehealth services from home to continue to report services under their office address. But “absent Congressional action, beginning January 1, 2025, the statutory restrictions on geography, site of service, and practitioner type that existed prior to the COVID-19 PHE will go back into effect,” CMS writes.
Transfer of care modifiers proposed for 90-day surgical package codes
In a move that would dramatically impact surgical practices, CMS is proposing that practitioners use modifiers 54, 55 and 56 to report when they provide only the pre-operative, intraoperative or post-operative portions of a 90-day global procedure. “We are proposing for practitioners to report the transfer of care modifiers in all transfer of care scenarios, which will provide CMS with more accurate information on the resources involved in furnishing components of global surgical packages,” the agency stated in a fact sheet on the rule. In addition, CMS is proposing a new add-on code, GPOC1, to be reported for post-operative care services that would more appropriately reflect time and resources involved in those services, the agency stated.
More (advanced) care management on the way
Advanced primary care management services (APCM) will debut next year if CMS implements a new enhanced care program, which includes three new codes and participation in a quality-based program.
“The proposed APCM services would incorporate elements of several existing care management and communication technology-based services into a bundle of services that reflects the essential elements of the delivery of advanced primary care, including principal care management, transitional care management, and chronic care management,” CMS writes in a fact sheet about the proposed rule.
Physicians and non-physician practitioners who act as the focal point for the patient’s health care services and are responsible for the patient’s primary care services, which are described by the primary APCM code. The services include overall comprehensive care management, making sure patients receive necessary preventive services, coordination of care with other practitioners and ensuring access to virtual methods of care such as online portals.
Extra opportunity for inherent complexity
More opportunities to report the office/other outpatient complexity add-on code (G2211) could open up next year. CMS will allow providers to report G2211 on the same day as an annual wellness visit, the administration of a vaccine or any Medicare Part B preventive service. The agency is proposing the change in response to complaints that current restrictions interfere with the way patients receive treatment, even though CMS has reviewed the available data and “cannot conclude from this analysis that our policy to deny payment of [G2211] when the … base code is reported on the same day as a preventive immunization or other Medicare preventive service is disruptive to the way such care is usually furnished.”
CMS seeks expansion of PT, OT supervision
In the 2024 rule CMS relaxed some supervision standards for enrolled physical and occupational therapist (PT/OT), allowing remote therapeutic monitoring (RTM) services to be furnished by their assistants (PTA/OTA) under general rather than direct supervision rules if they’re in private practice. Now CMS proposes to extend this relaxation to all physical and occupational therapy services performed by these assistants in private practice and in an outpatient setting, and if it complies with state law. CMS also proposes to make the physician/NPP signature timing requirements for initial certification of physical, occupational and speech language therapy less burdensome.
Take a peek at new codes and new (proposed) services
Practices can get a first glimpse of new codes they can expect to see in the 2025 CPT manual in the proposed fee schedule, as CMS proposes work valuations for them. The agency also floated new HCPCS services. Here are some of the code additions to anticipate (note that the codes listed for them are placeholders, not the final codes):
Skin cell suspension autograft. Eight new codes in the integumentary system section (15XX1-15XX8) will allow reporting of harvest, preparation and application of skin for skin cell suspension autograft of varying graft sizes. CMS disagrees with the RUC recommended work value for the new codes and is instead proposing that they be carrier priced.
Bundled code for interpositional arthroplasty. Hand surgeons should expect a new code (2X005) that combines tendon transfer (26480 and intercarpal or carpometacarpal interpositional arthroplasty (25447).
CAR-T Therapy moves from Category III to Category 1. Four new codes (3X018-3X021) will report Chimeric antigen receptor T-cell therapy. The codes include harvest of blood-derived T lymphocytes, preparation and administration of genetically modified CAR-T cells.
Intra-abdominal tumor excision or destruction. Five new codes (4X015-4X019) will describe open excision or destruction of peritoneal, mesenteric or retroperitoneal tumors or cysts by maximum length.
Two new bladder neck and prostate procedure codes. Codes 5XX05 and 5XX06 use insertion and removal of a temporary device to relieve lower urinary tract symptoms secondary to benign prostate hyperplasia.
Thoracic fascial plane blocks. Expect six new codes (6XX07-6XX12) for fascial plane blocks in the chest (thoracic) and lower extremities, including imaging guidance when performed. These new codes join existing transverse abdominus plane (TAP) blocks, 64486-64489.
Inpatient or observation infectious disease care. To account for additional complexity of care when infectious diseases are involved, CMS proposes a new add-on HCPCS code, GIDXX (Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment).
The code, which is projected for a work RVU of 0.89, “is meant to capture the visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant,” the agency writes in the proposed rule. The code should capture additional work “that is not accounted for in the appropriate hospital inpatient or observation E/M base code billed by the infectious disease physician.”
CMS intends the code to be an add-on to initial and subsequent inpatient and observation codes 99221-99223 and 99231-99236.
CMS fine tunes QPP, set 2029 MVP date
For the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP), you’ll find updates to the MIPS Value Pathways (MVP) program that CMS sees as the future of the MIPS program, including six new MVPs and an “APP Plus quality measure set” adjustment to the APM Performance Pathway (APP) scoring mechanism. CMS says MVPs will become mandatory for MIPS participants in 2029, and will issue a Request for Information on how to make that work. "This timeline would ensure MVPs may be voluntarily reported during a period of 6 to 7 years while traditional MIPS is available, allowing clinicians time to prepare for MVP reporting and to engage in the development of the MVP inventory," CMS says.
In MIPS scoring, the performance threshold will remain at 75 points and the data completeness criterion 75% through 2028. Quality will be 30%, cost 30%, improvement activities 15%, and promoting interoperability 25% of the MIPS score.
In the Advanced APM program, qualifying APM Participants (QP) will, as before, receive 0.75% conversion factor adjustment and a 1.88% APM Incentive Payment “bonus.”
Agency floats advance Shared Savings payments
For accountable care organizations (ACs) in the Medicare Shared Savings Program (MSSP) that have a good track record of earning savings, CMS proposes a “prepaid shared savings” plan, with “advances of earned shared savings that [eligible ACOs] can use to make investments that would aid beneficiaries, including beneficiaries in underserved communities.” Half of the advance payments would be have to be spent on direct beneficiary services that do not receive traditional Medicare payments.
The aforementioned APP Plus scoring method under QPP would also be available to MSSP ACOs. CMS proposes to adjust ACOs’ performance assessment benchmark with a new Health Equity Benchmark Adjustment (HEBA).
CMS also says a response to the “significant, anomalous, and highly suspect (SAHS) billing activity” the agency detected on some MSSP ACO durable medical equipment claims earlier this month, and a plan to avoid and equitably adjust scores for such incidents, will be addressed in future rulemaking.
Behavioral health growth hinges on safety, digital
CMS intends “advancing access to behavioral health” with new “safety planning intervention” services – that is, “a patient working with a clinician to develop a personalized list of coping strategies and sources of support that the person can use in the event of experiencing thoughts of harm to themselves or others.”
This can be billed with an add-on code to E/M or psychiatry visits, GSPI1 (Safety planning interventions, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health professionals or agencies; and making the environment safe).
The safety planning code will be valued based on 90839 (Psychotherapy for crisis) and a typical time of 20 minutes is assumed.
Providers following up on emergency department visits for similar issues may perform post-discharge telephonic follow-up contacts intervention (FCI), using code GFCI1 (Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, per calendar month). Providers will have to “obtain verbal (or written) beneficiary consent in advance of furnishing the services.” No time value is assumed yet for this but it will be valued based on the principal care management code 99426.
CM also proposed “digital mental health treatment” (DMHT) services, involving “digital cognitive behavioral therapy” (aka digital CBT) and using FDA-approved “digital mental health treatment (DMHT) device[s].”
The associated codes are GMBT1 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan), GMBT2 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the DMHT) and GMBT3 ( … ; each additional 20 minutes). CMS asks for comments as to payment and other service details.