The Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Final Rule was published on November 1, 2024. Many changes were scheduled to take place on January 1, 2025, and providers should understand the new regulations and guidelines to stay compliant with billing and coding practices. The Medicare PFS final rule, along with other Medicare final rules, addresses the need for an equitable healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation for all Medicare beneficiaries.
The Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Final Rule was published on November 1, 2024. Many changes were scheduled to take place on January 1, 2025, and providers should understand the new regulations and guidelines to stay compliant with billing and coding practices. The Medicare PFS final rule, along with other Medicare final rules, addresses the need for an equitable healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation for all Medicare beneficiaries.
Medicare beneficiaries will see changes in prescription drug costs, expanded mental health coverage, additional caregiver support, and changes to telehealth coverage. The standard Medicare Part B premium has not been finalized as of this writing; however, it is projected to increase to $185 per month in 2025. The Medicare Part A and Part B deductibles are also expected to see an increase.
By factors specified in law, average payment rates under the PFS will be reduced by 2.93% in CY 2025, compared with the average amount these services were paid during most of CY 2024. The change to the PFS conversion factor incorporates the 0% overall update required by statute, the expiration of the temporary 2.93% increase in payment for CY 2024 required by statute, and a relatively small estimated 0.02% adjustment necessary to account for changes in work relative value units for some services. This amounts to an estimated CY 2025 PFS conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29.
The centers for Medicare & Medicaid Services (CMS) is finalizing the proposal to establish new coding and payment for caregiver training for direct care services and support, which includes items such as techniques to prevent decubitus ulcer formation, wound care, and infection control. They are also finalizing the establishment of new codes and payment for caregiver behavior management and modification training that can be furnished to the caregiver(s) of an individual patient.
In CY 2024, Medicare approved HCPCS code G2211 to indicate the complexity of an evaluation and management (E/M) visit that’s part of an ongoing patient–physician relationship when the practitioner is the primary focal point for the patient’s healthcare needs. CMS did not approve the use of modifier 25 with code G2211. For CY 2025, CMS is finalizing the proposal to allow payment for G2211 when E/M codes 99202-99205 and 99211-99215 are reported by the same practitioner on the same day as an annual wellness visit, vaccine administration, or any Medicare Part B preventive service, including the initial preventive physical examination, furnished in the office or outpatient setting.
Telehealth services have undergone many changes since the start of the COVID-19 pandemic. During the COVID-19 pandemic, CMS implemented telehealth waivers to facilitate access to healthcare while minimizing the risk of transmission. These waivers allowed healthcare providers to offer a broader range of services via telehealth, ensuring that patients could receive care without having to travel to healthcare facilities. The waivers also expanded Medicare coverage of telehealth services, allowing for services to be delivered and received safely during the pandemic. This helped in maintaining public health and ensuring continuous access to care for Medicare beneficiaries during an unprecedented global health crisis.
Beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 public health emergency will retake effect for most telehealth services. These include geographic and location restrictions on where the services may be provided and limitations on the scope of practitioners who can provide Medicare telehealth services. However, the final rule reflects CMS’ goals to preserve some important, but limited, flexibility in its authority and expand the scope of and access to telehealth services where appropriate.
CMS is finalizing 3 new G codes for advanced primary care management services for people with chronic conditions. The codes include:
The CMS Innovation Center is finalizing coding and payment for an atherosclerotic cardiovascular disease (ASCVD) risk assessment service and risk management services. The ASCVD risk assessment will be performed in conjunction with an E/M visit when a practitioner identifies a patient at risk for cardiovascular disease (CVD) who does not have a diagnosis of CVD.
CMS will continue its actions to support behavioral health initiatives for Medicare beneficiaries in conjunction with the CMS Behavioral Health Strategy. Payment is being finalized for a G code that may be billed in 20-minute increments when safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose, are personally performed by the billing practitioner.
Medicare is expanding coverage for hepatitis B vaccines and colorectal cancer screening. Medicare is updating colorectal cancer screening by removing barium enema as a screening method and adding computed tomography colonography.
The “donut hole” is a term used to describe a coverage gap in Medicare Part D prescription drug plans. It is a period during which beneficiaries may pay more out of pocket for their medications after they and their plan have spent a certain amount on covered drugs. Once in the donut hole, beneficiaries are responsible for a larger share of their prescription medication costs until they reach the threshold for catastrophic coverage.
Beginning in CY 2025, out-of-pocket drug costs will be capped at $2000. If a beneficiary has Medicare drug coverage (Part D) and their drug costs are high enough to reach this cap, they do not have to pay a copayment or coinsurance for Part D drugs for the rest of the calendar year.
Beneficiaries will also have the option of spreading their drug costs across monthly payments throughout the year. This new payment option works with their current drug coverage to help manage out-of-pocket drug costs, by spreading them across the calendar year (January-December). This payment option might help manage prescription drug expenses; however, it does not save the beneficiary money or lower drug costs. If the beneficiary selects the payment plan option, they will continue to pay their plan premium and they will also receive a bill from their health or drug plan to pay for their prescriptions instead of paying the pharmacy. All plans are required to offer a payment plan; however, participation is voluntary.
Many changes are headed our way in 2025. For complete Medicare PFS Final Rule information visit www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule. Understanding the changes will help you support your Medicare patients and guide them through new services and benefits.