The Part B fee cuts are coming. After CMS proposed an across-the-board 2.8% reduction to the Medicare Part B conversion factor in July, the agency today confirmed that the rate-setting reduction is on track to kick in on Jan. 1, 2025.
Within the 3,088 page final 2025 Medicare physician fee schedule that was released this afternoon, CMS also finalized a diverse range of new service, such as caregiver training and a host of mental health-adjacent codes, largely punted on telehealth reform, confirmed the requirement of surgical transfer of care modifiers, and tweaked its quality-reporting programs.
But perhaps the biggest news is the rate cut, which many advocacy organizations had objected to since the proposed rule dropped over the summer. Within a half hour of the final rule’s release, the AMA issued a statement calling on lawmakers to step in and reform the “broken reimbursement system” that is Medicare Part B, and the Medical Group Management Association (MGMA) said it "throws the financial viability of physician practices into question and threatens beneficiary access to care. "
As proponents of a rate increase didn’t get their way, they actually saw the final conversion factor dip – ever so slightly – beneath the original July proposal. On Jan. 1, the 2025 conversion factor will be $32.3465, down from the proposed rate of $32.3562. As the chart below shows, the percentage drop remains steady at -2.8%.
The final anesthesia conversion also decreased from the proposal, now coming in at $20.3178, a -2.2% decrease year over year.
Calculating the final CY 2025 PFS conversion factor (CF)
| CY 2024 CF (3/9-12/31, 2024) |
CY 2025 CF (final) |
YTY % change |
| $33.2875 |
$32.3465 |
-2.8% |
| CY 2024 anesthesia CF (3/9-12/31, 2024) |
CY 2025 anesthesia CF |
YTY % change |
| $20.7739 |
$20.3178 |
-2.2% |
*Note: All rates are final
Take note of various other service areas, billing rules and reporting requirements contained in the final rule.
Complexity of care add-on expansion approved
Providers will be able to report complexity of care add-on code G2211 with an office/other outpatient E/M visit (99202-99215) when the patient receives an annual wellness visit, vaccine administration or any covered preventive service on the same day. Under current policy, appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code will prompt a denial of the add-on code. CMS will loosen its policy and allow payment when the E/M code is reported with the listed services, effective Jan. 1.
CMS finalizes time-less advanced primary care management (APCM) codes
The new year will usher in three new care management codes, but there will be something different about the APCM set. The codes don’t have specific time requirements so practices will not have to keep track of the minutes treating providers and ancillary staff spend on the services within a calendar month. CMS skipped time requirements “to reduce the administrative burden associated with current coding and billing,” according to a press release for the final 2025 Medicare physician fee schedule. The agency instead finalized its proposed tier-based set. Code G0556 (Level 1) is for patients with one chronic condition. G0557 (Level 2) is for patients who have two or more chronic conditions and G0558 (Level 3) should be reported when the patient has two or more chronic conditions and is a Qualified Medicare Beneficiary.
CMS also boosted the final work relative value units (RVU) for a Level 1 APCM to 0.25, after commenters convinced the agency that the wRVU of 0.17 was too low.
CMS did not place limits on the specialties that can perform the service, but the agency will only pay one provider per patient per month for an APCM service and stressed the importance of explaining the service to the patient and getting patient consent in order to avoid unexpected denials.
Say goodbye to G2012, hello to 98016
CMS will delete virtual check-in code G2012 next year and adopt the new CPT code 98016 (Brief communication technology-based service [eg, virtual check-in] by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion). The rules for the code will stay the same. For example, it must be initiated by an established patient and should be used to determine whether the patient needs to be seen in person.
CMS maintains telehealth address waiver
Even though the last of the COVID-19 public health emergency waivers will expire at midnight, Jan. 1, 2025, CMS believes it can extend a few waivers. For example, through 2025, “we will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home,” CMS wrote in a press release for the final rule.
Welcome digital mental health treatment (DMHT) services
Check out three DMHT codes that cover two therapeutic treatment management services (G0553 and +G0554) as well as a supply code for behavioral health treatment device (G0552). The therapeutic codes may be billed only when there is ongoing use of the DMHT device. To report the supply code G0552, you must meet the following conditions:
The DMHT device must have been previously approved by the Food and Drug Administration (FDA).
- Supplying the device “must be incident to the billing practitioner’s professional services in association with ongoing treatment under a plan of care by the billing practitioner,” CMS says.
- For G0552 to be payable, the billing practitioner must incur a cost to acquire and furnish the DMHT device.
Full DMHT descriptors
Check out the full descriptors of the DMHT services, which will be reportable Jan. 1, 2025:
- G0552 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan)
- G0553 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment [DMHT] device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month)
- +G0554 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment [DMHT] device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month. [List separately in addition to HCPCS code G0553])
Interprofessional consults for mental health
The agency also is covering a series of six HCPCS codes (G0546-G0551) for the coverage of interprofessional consults “by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis of mental illness,” according to the codes’ descriptors. The new codes “mirror current interprofessional consultation CPT codes used by practitioners who are eligible to bill E/M visits,” according to the press release.
Safety planning, assessment, follow-up
In another move that highlights CMS’ efforts to bolster mental health treatment access, the agency is finalizing the HCPCS code 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; and making the environment safe).
The code should be billed along with an E/M visit or psychotherapy service, as it establishes separate payment for safety planning interventions addressing a patient’s risk of harm to themselves or others.
Also coming in 2025 is a monthly code for follow-up care after a patient’s time of mental health crisis. For that code, turn to G0544 (Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, 4 calls per calendar month).
Medicare finalizes expansion of transfer of care modifiers
CMS will require use of modifiers 54 (Surgical care only), 55 (Post-operative management only and 56 (Pre-operative management only) for all 90-day global surgical packages when the practitioner provides only a portion of the global package. Practices that provide the full global surgical package would be exempt from the requirement, the agency states.
Surgical societies warned that the change could cause confusion among providers, particularly when the surgeon providing the procedure is unaware of clinicians billing for pre- or post-operative care. CMS said it was aware of “the potential challenge associated with anticipating whether other practitioners (or their group practices) will furnish post-operative care and, accordingly, appending the appropriate modifier when billing global package services.”
However, the agency states, “broadly, we emphasize the need to balance any potential administrative burden on practitioners and billers with accurate valuation and payment for global services.” CMS also finalized establishment of a new HCPCS add-on code, G0559, for post-operative follow-up visit complexity.
Therapists in private practice can provide general supervision for therapy assistants
Physical therapists and occupational therapists in private practice will be able to supervise their physical therapy assistants and occupational therapy assistants under less strict “general” supervision rules, as opposed to direct supervision rules. The change will give therapy practices more flexibility to meet the needs of patients, CMs predicts. The agency is also finalizing a change to certification of therapy plan requirements to provide an exception to the physician/nonphysician practitioner signature requirement on therapist-established treatment plans.
New overpayments rules: FCA standard, 180-day window
The rule finalizes two major changes for Part A and B overpayments: The current “reasonable diligence” standard for discovery of overpayments will be replaced by the “knowing” or “knowingly” standard used in the False Claims Act (FCA); and the current 60-day report-and-repay timeline is changed to a 180-day period within which a “timely, good faith investigation to determine the existence of related overpayments that may arise from the same or similar cause or reason as the initially identified overpayment” may be conducted and the debt repaid. (Many commenters to the proposed rule sought a longer period than 180 days, but were rebuffed.)
Quality Payment Program: MVP in mind but no date
With the Quality Payment Program (QPP) and the Merit-Based Incentive Payment System (MIPS), CMS remains focused on the MIPS Value Pathways (MVP) model, which gets new requirements and measures, but while the agency says it will “sunset traditional MIPS in the future” and replace it with MVP, “that future date has not been determined and will be established through the official notice and comment rulemaking process.”
Tthe current MIPS performance threshold policies stay at 75 points for the CY 2025 performance period/2027 payment year, as will the MIPS 75% data completeness criteria threshold through the 2028 performance period/2030 payment year.
For accountable care organizations (ACO) participating in MIPS as a MIPS APM, CMS has finalized the Alternative Payment Model (APM) Performance Pathway (APP) Plus quality measure set. Savings Program ACOs will be required to report the APP Plus quality measure set to meet their quality performance requirements.
Shared Savings go ‘prepaid’ for some; equity benchmark established
The rule finalizes an interesting new path for Medicare Shared Savings Plan (MSSP) participants: a “prepaid” plan in which participants get their savings up front — instead of not getting them until after they’ve demonstrated saving the program money – in exchange for providing “direct beneficiary services … not otherwise payable in traditional Medicare,” such as meals, dental, vision, or hearing, with at least 50% of the savings. Other prepaid savings may be spent on staffing and health care infrastructure.
CMS finalizes as well a “Health Equity Benchmark Adjustment (HEBA)” that would adjust an MSSP ACO’s benchmark if at least 15% of assigned beneficiaries are enrolled in Medicare Part D low-income subsidy (LIS) or are dually eligible for Medicare and Medicaid in order to – a switch from the proposed 20%.
Look to future Part B News issues for comprehensive coverage of the entire rule.