2025 CMS Payment Update Highlights
Physician Fee Schedule Overview:
The conversion factor has decreased from $33.29 to $32.35 (2.8$) for CY2025. This basically negates the 2.93% increase in CY 2024.
- Extended several telehealth waivers through 2025.
- Direct supervision expanded to include audio/video real-time communications, excluding audio-only, but only for services assigned a PC/TC indicator of "5", such as a 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) utilized for nurse visits.
- There are several updates to telehealth E&M services, that I'll continue to review and provide updates on as needed.
- CMS is changing the direct to general supervision requirement for Physical, Speech and Occupational Outpatient Therapy Services in private practices. All other outpatient therapies i.e.. HBOT, was not included, but it will be interesting to see if UHMS comments on this going forward.
- CMS continues to examine ways to treat skin substitutes products as incident-to supplies under PFS rate setting. They continue to evaluate how they will reimburse for these services going forward, but are not recommending any changes at this time for CY 2025.
- One statement did state that skin substitutes will be added to the product category that are not considered Part B rebatable drugs. (Section III.I)
- CMS continues to review opportunities for improving Global Surgery Payment Accuracy. This includes providers in the same group being able to bill separately for services post-surgery by a member of the same group. In addition, there is a change for care provided outside the surgical group, that is a common scenario impacting our providers when receiving post-surgical wound care referrals.
- Improvements in the transfer of care payment structure, including a modifier to denote follow-up care by a provider not in the same group or specialty of the surgeon.
- G0559 - Post-operative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90-day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care and requires the following required elements, when possible and applicable
- G0465 - Autologous platelet rich plasma (prp) or other blood-derived product for diabetic chronic wounds/ulcers, using an fda-cleared device for this indication, (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment). Pricing for this code will be mapped to 15275 and finalized reimbursement of $770.83 for CY2025. Individual MACs will need to be monitored.
OPPS Overview: To be published on 11/27/2024
- OPPS payment rate for outpatient departments in CY 2025 will increase by a factor of 2.9%. There continues to be a 2.0 percentage point reduction for hospitals that fail to meet outpatient quality reporting requirements.
- HBOT G0277 - CY 2024 $132.21 to CY 2025 $137.90 per 30 minute segment. CMS-1809-FC | CMS
- Skin substitutes will continue to be assigned to high/low categories in CY 2025 with the same methodology as CY 2024. There is no further mention of the reduction in products approved in the final rule or LCDs at this time.