Physician fee schedule final rule

The Facilities for Medicare & Medicaid Companies (CMS) has posted the 2025 Medicare doctor payment schedule closing rule. This AASM evaluation highlights adjustments in doctor cost and sleep drugs reimbursement, particular Present Procedural Terminology (CPT) code updates, revisions to telehealth insurance policies, and cost for dental and oral well being companies.

Doctor Fee

The AASM continues to advocate for Medicare doctor cost reform, as we encourage Congressional leaders to #RepairMedicare by means of AASM-led efforts in addition to coordinated efforts with the American Medical Affiliation (AMA) and different medical societies and organizations. These continued payer advocacy initiatives included an AASM response to the 2025 doctor payment schedule proposed rule, wherein we strongly opposed the proposed conversion issue. Nevertheless, a diminished conversion issue of $32.3465 was finalized, setting in place a 2.83% discount from 2024. See Desk 1.

The AASM continues to advocate for an annual inflationary replace to deal with the downward pattern in doctor reimbursements and encourages members to go to the AASM Motion Heart and be a part of the present payer advocacy marketing campaign to encourage Congressional leaders to signal on as co-sponsors of the Medicare Affected person Entry and Observe Stabilization Act of 2024 (H.R. 10073), which might give physicians a 4.73% cost enhance in calendar yr 2025. This cost enhance would counteract the Medicare Financial Index (MEI) prediction that the price of working towards drugs will enhance by 3.6% in 2025.

The affect of the persistently reducing conversion issue may be seen within the downward pattern in reimbursements for sleep research. See Desk 2 and Desk 3.

Fee and RVU Comparisons

The AASM has put collectively up to date nationwide cost and relative worth unit (RVU) comparability paperwork, which can be found utilizing the hyperlinks beneath.

Estimated Specialty Utilization

CMS additionally included data that parses out the mixture estimated doctor payment schedule allowed expenses for every specialty primarily based on 2023 utilization information and 2024 reimbursement charges, to reveal the potential affect of the finalized insurance policies on this closing rule. The company predicted no mixed affect for vital care, neurology, otolaryngology, or pulmonary illness. Nevertheless, medical psychology is predicted to have a mixed affect of three% throughout each non-facility and facility allowable expenses, whereas pediatrics is predicted to have a mixed affect of 1% in facility expenses, and psychiatry is predicted to have a mixed affect of 1% in non-facility expenses. Sleep drugs will not be included, as CMS categorizes it as a subspecialty.

Particular CPT Code Updates

Telemedicine E/M Workplace Go to codes (98000 – 98015)

The American Medical Affiliation CPT Editorial Panel beforehand established 17 new telemedicine analysis and administration (E/M) workplace go to CPT codes, which have been meant to seize audio-only companies in addition to audio-visual companies. As soon as established, these codes have been valued by the AMA/Specialty Society Relative Worth Scale Replace Committee (RUC). The RVU suggestions have been then submitted to CMS for evaluate and adoption. Nevertheless, whereas CMS has finalized proposals to publish the brand new codes and the really useful values, it didn’t undertake the codes to be used within the Medicare program, because the company doesn’t imagine that these companies ought to be carried out for Medicare with out new laws being enacted. As an alternative, CMS acknowledged the deletion of the audio-only phone companies CPT codes, 99441 – 99443, and it dedicated to creating academic supplies to help with right coding for audio-only vs. audio-video telemedicine companies going ahead.

Refinement of present coverage for implementation of G2211

Whereas the Healthcare Frequent Process Coding System (HCPCS) code G2211 was carried out at first of 2024, CMS initially prohibited reporting this code on the identical day as preventive companies, together with annual wellness visits and vaccinations. Nevertheless, CMS has refined the coverage to permit cost for G2211 when E/M visits are supplied by the identical doctor or certified well being care skilled to the identical affected person on the identical day as one other serviced and billed with CPT modifier 25. The AASM encourages members to meticulously doc when reporting G2211, as there are typically audits after preliminary implementation of latest, broadly used CPT codes. Members are additionally inspired to evaluate the AASM’s Coding Quarterly article in Montage journal relating to right reporting of G2211.

Adoption of latest code to switch G2012

CMS finalized the adoption of CPT code 98016 rather than the HCPCS code G2012 for reporting a short communication technology-based service, which has a non-facility cost charge of $15.85 and a facility cost charge of $14.56.

95800 as a probably misvalued code

For 2 years in a row, CPT code 95800 was submitted as a probably misvalued code, because the submitter indicated that almost all of sleep drugs suppliers have switched to utilizing disposable gear slightly than reusable gear for unattended diagnostic sleep research reported by way of 95800. Once more, AASM responded to this nomination by urging CMS to gather extra information earlier than making a closing choice on updating the follow expense data for this code. The AASM can also be working with the American Academy of Neurology (AAN), American Thoracic Society (ATS), and the American School of Chest Physicians (CHEST) to revise the unattended sleep testing codes so sleep drugs professionals can report codes precisely for brand spanking new applied sciences and report diagnostic testing for a number of sleep issues.

Revisions to Telehealth Insurance policies

With out Congressional motion, pre-pandemic geographic and placement restrictions shall be reinstated as of Jan. 1, 2025. Which means until a Medicare affected person lives or is positioned in a well being skilled scarcity space, a rural census observe, or a county outdoors of the metropolitan statistical space on the time of service, they won’t be lined for telehealth companies. Limitations on the scope of suppliers that may present Medicare telehealth companies can even be reinstated absent Congressional motion.

The AASM is supporting the Telehealth Modernization Act of 2024 (H.R. 7623), which might completely prolong sure flexibilities and permit (1) rural well being clinics and federally certified well being facilities to function the distant web site, (i.e., the placement of the well being care practitioner); (2) the house of a beneficiary to function the originating web site (i.e., the placement of the beneficiary) for all companies (slightly than for less than sure companies); and (3) all sorts of practitioners to furnish telehealth companies as decided by CMS.

Extra telehealth insurance policies finalized by CMS, as really useful by AASM, embrace:

Suppliers could use two-way, real-time, audio-only communication for Medicare telehealth companies furnished to a beneficiary of their residence so long as the supplier has video capabilities, no matter whether or not the affected person is succesful or consents to utilizing video expertise.
Direct supervision by means of real-time audio and visible interactive telecommunications (not audio-only) will proceed to be allowed on qualifying companies.
A number of behavioral and psychological well being companies shall be completely provided beneath telehealth for Medicare sufferers starting in 2025.
Place of service (POS) codes will proceed to have two telehealth designations:

POS 02 Affected person not of their residence when telehealth companies are rendered; or
POS 10 Affected person of their residence when telehealth companies are rendered.

CMS will proceed to permit physicians to checklist their follow handle, slightly than their residence handle, when performing Medicare companies by way of telehealth from their residence.
Instructing physicians could proceed to have a digital presence in all educating settings by means of Dec. 31, 2025, however just for Medicare telehealth companies.
CMS additionally finalized the adoption of three new digital psychological well being therapy codes, G0552 – G0554. The AASM requested that CMS modify the categorization of the codes to “digital well being therapy” codes and to change the code descriptors to permit for broader implementation and to incorporate units that don’t routinely transmit information to suppliers. Nevertheless, these modifications weren’t finalized. The code descriptors are supplied beneath.

Medicare cost for dental/oral well being companies

In 2023, CMS finalized that Medicare cost might be made when dental companies are linked to, associated, and integral to the medical success of different Medicare lined companies and has since added extra dental companies to the checklist of Medicare lined companies. On this 2025 closing rule, the company has expanded protection and cost to incorporate:

Medically obligatory diagnostic and therapy companies to eradicate an oral or dental an infection earlier than or contemporaneously with Medicare-covered dialysis companies for the therapy of end-stage renal illness (ESRD).
Dental or oral examination within the inpatient or outpatient setting earlier than or contemporaneously with Medicare-covered dialysis companies for the therapy of ESRD.

CMS additionally finalized that the company will delay implementation for each the ICD-10 codes in addition to KX and GY administrative claims modifiers till July 1, 2025, to permit extra time for complete testing, reporting, and academic supplies for suppliers, distributors, and payers.

Lastly, after reviewing responses from many medical organizations, together with the AASM, in response to a request for data relating to companies related to furnishing an oral equipment for the therapy of obstructive sleep apnea (OSA), CMS didn’t make a closing dedication.

Members could ship questions concerning the Medicare doctor payment schedule closing rule to coding@aasm.org.