CMS Releases 2025 Medicare Payment Proposed Rule

On July 10, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule for the 2025 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP). The rule now enters a 60-day public comment period, after which the rule will be finalized before taking effect on January 1, 2025. To view The US Oncology Network’s statement on the proposed rule, CLICK HERE.

Key highlights from the proposed rule include:

Payment Policy Changes
The proposed CY 2025 PFS conversion factor is $32.36, a decrease of $0.93 (or 2.80%) from the CY 2024 PFS conversion factor of $33.29. This conversion factor accounts for the statutorily-required update to the conversion factor for CY 2025 of 0%, the expiration of the 2.93% increase for 2024 provided by the Consolidated Appropriations Act of 2024, and a 0.05% statutorily-required budget neutrality adjustment to account for changes in Relative Value Units.

Beyond the -2.80% impact related to the conversion factor, changes in payment policy outlined in the proposed rule result in the overall average impact for the following specialties:

• Hematology/Oncology: 0%
• Radiation Oncology and Radiation Therapy Centers: 0%
• Urology: -1%
• Rheumatology: 0%
• Gastroenterology: 0%
• Diagnostic Testing Facility: -2%
• Independent Laboratory: 0%
• Ophthalmology: -1%
• General Surgery: 0%

*Note, the specialty impact estimates above do not account for the reduced conversion factor.

Telehealth Services
CMS is proposing beginning January 1, 2025, 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 physician or 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 is also proposing, for a certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising practitioner, to permanently adopt a definition of direct supervision that allows the physician or supervising practitioner to provide such supervision through real-time audio and visual interactive telecommunications. CMS is specifically proposing that the physician or supervising practitioner may provide such virtual direct supervision for services furnished incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of office or other outpatient visit for the evaluation and management of an established patient who may not require the presence of a physician or other qualified health care professional. For all other services furnished under the direct supervision of the supervising physician or other practitioner, CMS is proposing to continue to define “immediate availability” to include real-time audio and visual interactive telecommunications technology only through December 31, 2025.

Office/Outpatient (O/O) Evaluation and Management (E/M) Visits
For CY 2025, CMS is proposing to allow payment of the O/O E/M visit complexity add-on code G2211 when the O/O E/M base 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.

Strategies for Improving Global Surgery Payment Accuracy
For CY 2025, CMS is proposing to broaden the applicability of the transfer of care modifiers for global packages and require the use of the existing modifiers (-54, -55, and -56) for all 90-day global surgical packages in any case when a practitioner (or another practitioner from the same group practice) expects to furnish only the pre-operative (-56), procedure (-54), or post operative portions of a global package (including but not limited to when there is a formal, documented transfer of care as under current policy or an informal, non-documented but expected, transfer of care).

For CY 2025, CMS is also proposing a new add-on code, GPOC1, for post-operative care services to more appropriately reflect the time and resources involved in these post-operative visits to compensate the additional resources involved by practitioners who were not involved in furnishing the surgical procedure.

Payment for Radiopharmaceuticals in the Physician Office
CMS is proposing to clarify that, for radiopharmaceuticals furnished in a setting other than a hospital outpatient department, Medicare Administrative Contractor (MACs) shall determine payment limits for radiopharmaceuticals based on any methodology used to determine payment limits for radiopharmaceuticals in place on or prior to November 2003. Such methodology may include, but is not limited to, the use of invoice-based pricing.

Health-Related Social Needs
For CY 2025, CMS is issuing a broad RFI on the newly implemented Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment to engage interested parties on additional policy refinements for CMS to consider in future rulemaking. They request information on other factors to consider such as types of auxiliary personnel and other certification and/or training requirements that are not adequately captured in current coding and payment for these services and how to improve utilization in rural areas.

Caregiver Training Services (CTS)
For CY 2025, CMS is proposing to a establish new coding and payment for caregiver training for direct care services and supports. The topics of trainings could include, but would not be limited to, techniques to prevent decubitus ulcer formation, wound dressing changes, infection control, special diet preparation, and medication administration. CMS is also proposing to establish new coding and payment for caregiver behavior management and modification training that could be furnished to the caregiver(s) of an individual patient. CMS is also proposing to allow the proposed CTS to be furnished via telehealth.

Requiring Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts
CMS is proposing the JW modifier if a billing supplier is not administering a drug, but there are discarded amounts discarded during the preparation process before supplying the drug to the patient.

Clinical Laboratory Fee Schedule (CLFS)
CMS is revising the next data reporting period and phase-in of payment reductions for clinical diagnostic laboratory tests (CDLTs) that are not advanced diagnostic laboratory tests (ADLTs) for January 1, 2025, through March 31, 2025, and will continue to be based on the data collection period of January 1, 2019, through June 30, 2019.

Expand Colorectal Cancer Screening
CMS is proposing to remove coverage of barium enema as a method of screening. CMS is also proposing to expand coverage for colorectal cancer screening (CRC) screening to include Computed Tomography (CT) Colonography.

CMS is also proposing to expand their approach to a “Complete CRC Screening” finalized in the CY 2023 PFS by adding that either a positive Medicare-covered blood-based biomarker test or non-invasive stool-based test is part of the CRC screening continuum and the follow-on colonoscopy would not incur beneficiary cost-sharing.

Medicare Prescription Drug Inflation Rebate Program
CMS is proposing policies that include, but are not limited to, the following:

• Establishing the method and potential data sources to remove 340B units from the total number of units used to calculate the total rebate amount for a Part D rebatable drug.
• Establishing the method and process for reconciliation of a rebate amount for Part B and Part D rebatable drugs, including the circumstances that may trigger such a reconciliation.
• Clarifying rebate calculations for Part B and Part D rebatable drugs in specific circumstances, including exclusion of Part B units of single-dose container or single-use package drugs subject to discarded drug refunds.

CY 2024 Updates to the Quality Payment Program

• CMS is introducing 6 new MVPs for the 2025 performance period that are related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.
• CMS is creating APP Plus, an additional quality measure set under the APP, which would include the 6 measures currently in the APP quality measure set and incrementally incorporate the remaining 5 Adult Universal Foundation quality measures for a total of 11 measures by the 2028 performance period/2030 payment year.
• CMS is maintaining the current performance threshold policies, leaving the performance threshold set at 75 points for the 2025 performance period.
• CMS is keeping the 75% data completeness criteria through the 2028 performance period.

CMS is also seeking feedback on RFIs on the following topics:

• Guiding principles for the development of patient-reported outcome quality measures
• MVP adoption and subgroup participation
• Public Health and Clinical Data Exchange Objective under the Promoting Interoperability performance category

The US Oncology Network will submit comments on the proposed rule prior to the September 9^th deadline.

To read the CMS press release on the PFS proposal, CLICK HERE.

To read the CMS fact sheet on the PFS proposal, CLICK HERE.

To read the CMS fact sheet on the QPP proposal, CLICK HERE.

To read the PFS/QPP proposed rule in its entirety, CLICK HERE.