CMS Releases 2025 Final Rule for the Physician Fee Schedule

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a rule finalizing changes for Medicare payments under the PFS and other Medicare Part B policies, effective on or after January 1, 2025. This highly anticipated rule features significant changes, particularly for RHCs though includes a number of changes for the Quality Payment Program (QPP) as well as hospital and clinic services.

 

• Allowing RHCs to bill for administration of Part B preventive vaccines (COVID-19, pneumococcal, influenza, and Hepatitis B) at time of service, not entirely in a lump sum settlement on cost report, beginning July 1, 2025
• Eliminating RHC productivity standards for cost report periods ending after December 31, 2024
• Completely revising RHC care management billing with the elimination of the G0511 consolidated code
• Establishing new “Advanced Primary Care Management Services” billing opportunities
• Removing Hemoglobin/Hematocrit and examination of stool specimens for occult blood from the list of required RHC lab services (RHCs will only have FOUR required labs after 1/1/25)
• Clarifying guidance versus regulatory discrepancies in how “primarily engaged in primary care” is defined and enforced
• Expanding the same day billing flexibilities for dental services able to be furnished in RHC setting
• Modifying Intensive Outpatient Program (IOP) Services payment to allow for reimbursement of three and four-service days
• Extending Medicare telehealth flexibilities until December 31, 2025

The majority of these policies will go into effect January 1, 2025, unless otherwise specified below.

 

Background: The RHC statute requires that influenza, COVID-19, and pneumococcal vaccines and their administration to Medicare patients be reimbursed at 100% of reasonable costs, instead of the 80% limit that applies to other services. The hepatitis B vaccine has historically been reimbursed as part of the RHC All-Inclusive Rate, however no insurance or deductible applies given that it is a preventive service. This can result in cash flow issues due to the wait time between purchasing and administering vaccines and the cost report settlement.

 

CMS is finalizing a proposal to allow RHCs to bill for the administration of pneumococcal, flu, COVID-19, and hepatitis B vaccines at time of service. These claims will initially pay like other Part B vaccine claims, at 95% of the Average Wholesale Price (AWP) for the vaccine product itself. Vaccine administration will be reimbursed according to the Part B Vaccine Administration National Fee Schedule, shown below, adjusted for locality.

 

Vaccine Administration Reimbursement:

G0008 (Flu) -- $33.71 (unadjusted)

G0009 (Pneumococcal) -- $33.71 (unadjusted)

G0010 (Hep B) -- $33.71 (unadjusted)

90480 (COVID-19) -- $44.95 (unadjusted)

 

To comply with the statutory requirements of paying 100% of reasonable costs for preventive vaccines however, RHCs will still reconcile with CMS on an annual basis to receive their full vaccine and administrative costs.

 

Additionally, CMS is making certain RHC providers eligible to bill HCPCS code M0201 when one of these four vaccines is administered in a patient’s home. This is approximately a $39.90 (unadjusted) additional reimbursement. To meet the criteria for receiving the in-home additional payment, RHCs must be in a designated home health shortage area and offer visiting nurse services, and the visit must also meet the requirements outlined below:

 

(A) The patient has difficulty leaving the home or faces barriers to getting a vaccine in settings other than their home.

(B) The sole purpose of the visit is to administer one or more preventive vaccines.

(C) The home is not an institution that meets the requirements of sections 1861(e)(1),1819(a)(1), or 1919(a)(1) of the Act, or §§ 409.42(a) of this subchapter.

 

To ensure CMS has time to issue new cost reporting instructions and sub-regulatory billing guidance to MACs and RHCs, these vaccine provisions will go into effect for dates of service beginning July 1, 2025.

 

Currently, RHC productivity standards are established as 4,200 visits per full-time equivalent(FTE) physician and 2,100 visits per FTE nurse practitioner, PA, and certified nurse midwife. Other RHC practitioners are not subject to productivity standards. Since all RHCs are now subject to some sort of upper payment limit (either the clinic specific cap for grandfathered RHCs or the national statutory cap for new and independent RHCs), the productivity standards have less impact as a guardrail and may have other negative implications.

 

CMS has finalized their proposal to eliminate productivity standards for RHCs, effective with cost reporting periods ending after December 31, 2024.

 

Background: Since 2016, RHCs have been able to bill for Chronic Care Management (CCM) services through a consolidated care management code: G0511. This special payment rule pays approximately $72.90 in 2024, which is the average of the Physician Fee Schedule (PFS) rates for CCM, principal care management (PCM) services, Chronic Pain Management, General Behavioral Health Integration, as well as codes newly added in 2024: Remote Physiological Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Community Health Integration (CHI), and Principal Illness Navigation (PIN) Services.

 

Beginning in 2024, the G0511 code was billable more than once per patient per month, so long as requirements are met, and resource costs are not double counted. However, the single consolidated code currently represents 22 care management services, and this aggregation has presented a myriad of billing issues.

 

CMS finalized their proposal to allow RHCs to bill the individual CPT codes that have historically comprised the G0511 code, instead of billing the consolidated code, G0511 itself.

Beginning January 1, 2025, RHCs should bill, on the UB-04 claim form, the CPT codes found in Table 28, when they provide care management services. While some of the fee schedule reimbursements may be lower than the consolidated rate of $72.90, this change means RHCs will be eligible to bill for add-on time-based codes, in addition to the primary care management codes.

CMS established a transition period for getting into compliance with the new billing structure. From January 1, 2025, through July 1, 2025, RHCs may bill either G0511 or the individual CPT codes in Table 28.  After July 1, 2025, G0511 will no longer be reimbursable.

 

CMS finalized, with a few changes, new codes for Advanced Primary Care Management (APCM) services, a set of three G-codes intended to bundle existing care management codes based on complexity of patient condition, not time spent on each patient’s care management activities, reimbursed as calendar month bundles. If an RHC billed for these codes, they would not bill for individual services explained above.

 

These codes will be structured as follows:

• G0556 – Patients with 0-1 chronic condition; ~$15 per month
• G0557 – Patients with two or more chronic conditions; ~$50 per month
• G0558 – Patients who are QMBs with two or more chronic conditions; ~$110 per month

Background: The RHC statute directs the HHS Secretary to ensure that RHCs provide routine diagnostic services. CMS has implemented this historically by requiring that RHCs have the equipment and supplies within the square footage of their RHCs to offer six specific lab services:

 

• chemical examinations of urine by stick or tablet method or both (including urine ketones);
• hemoglobin or hematocrit;
• blood glucose;
• examination of stool specimens for occult blood;
• pregnancy tests; and primary culturing for transmittal to a certified laboratory.

CMS is finalizing a proposal to remove hemoglobin and hematocrit (H&H) and examination of stool specimens for occult blood from the list of lab services that RHCs must have the equipment and supplies to provide directly within the RHC. This will mean that RHCS will only have four required labs moving forward.

 

Note: This regulatory change does not prohibit RHCs from continuing to provide these lab services within the facility, it simply offers additional flexibility in situations where this isn’t being used or is no longer appropriate.

 

Background: RHC statute and associated regulations stipulates that RHCs must be primarily engaged in “providing outpatient services.” However, CMS State Operations Manual Appendix G explains that “RHCs may not be primarily engaged in specialized services.”

 

CMS acknowledged the discrepancy that exists between the various documents that regulate the RHC program and in order to ensure greater flexibility in the outpatient services RHCs can provide, CMS finalized the below addition to the 491.9(2) regulation:

(i) The clinic or center must provide primary care services.

(ii) The clinic is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.

 

Background: RHC statute reads that a Rural Health Clinic is “only a facility which... (iv) is not a rehabilitation facility or a facility which is primarily for the care and treatment of mental diseases.” This has been interpreted to mean that RHCs can only provide up to 49% of their services as behavioral health services, without clear guidance as to how these services should be counted, and ultimately risking patient care access to these essential services.

In the proposed rule released this summer, CMS acknowledged that “mental diseases” is outdated terminology and may have additional negative impacts on stigma and help-seeking behavior but recognizes that this language is in the law governing the RHC program and can only be removed by Congress. However, they proposed that by defining “mental diseases” they could then issue guidance to assess an RHC’s compliance with the requirement in a more uniform way.

 

CMS ultimately withdrew this proposal in the Final Rule. They stated that their intention was not to further discourage the provision of RHC behavioral health services and acknowledged that the way they were going about defining “mental diseases” could result in just that.

 

Background: Medicare is precluded from paying for most dental services, including routine cleanings and treatment. However, exceptions are made for certain outpatient services if the dental service is “inextricably linked to, and substantially related and integral to the clinical success of, other covered services.”

 

This exception extends to RHCs, meaning that if the service meets the “inextricably linked” standard and is provided by a dentist in the RHC, it will qualify as an encounter and be paid the RHC’s All-Inclusive Rate. In these instances, the RHC should report the KX modifier to indicate that it meets these requirements, and that adequate documentation is in the medical record.

 

CMS expanded the list of “inextricably linked” medical services in the Final Rule. The “inextricably linked” dental services are a “dental or oral examination performed as part of a comprehensive workup prior to, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with” if related to the above conditions. Additionally, CMS finalized that when a medical encounter and a covered dental visit are provided to the same patient in the same day, they are eligible for an exception to the same day visit limitations in RHCs and will be paid as two separate billable encounters.

 

Background: Beginning in 2024, RHCs can furnish Intensive Outpatient Program (IOP) services, behavioral health services intended to serve patients who need care at a level equivalent to 9-19 hours of care per week. This reimburses outside of the All-Inclusive Rate via a special payment rule that corresponds to approximately three services per patient per day, $259.13.

 

Other providers eligible to bill for IOP services can receive either the 3-services-per-day payment rate, or the 4-services-per-day payment rate, depending on the number of services provided, but RHCs and FQHCs are limited to the lower payment rate, regardless of the number of services provided.

 

CMS will allow RHCs to bill for the three or four services per day IOP, depending on the number of services provided.

 

Background: Current Medicare medical telehealth flexibilities will expire on December 31, 2024, without Congressional action.

 

CMS finalized a proposal to continue current medical telehealth flexibilities for RHCs through 12/31/2025. RHCs will continue to bill G2025 for medical telehealth services and will be reimbursed approximately $97 per visit. These visits do not count as encounters and associated costs and visits must be carved out of the cost report.

Additionally, while mental health flexibilities are permanent, CMS further delayed the occasional in-person visit requirement prior to, and for the duration of those services, until January 1, 2026.

 

 

• CMS is maintaining current performance threshold policies, which will leave the performance threshold set at 75 points for the CY 2025 performance period/2027 MIPS payment year.
• CMS is maintaining the 75% data completeness criteria threshold through the 2028 performance period/2030 MIPS payment year. 
• CMS finalized 6 new MVPs that will be available beginning with the 2025 performance period related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.
• CMS finalized limited modifications to the previously finalized MVPs, including the consolidation of 2 neurology-focused MVPs into a single neurological MVP.
• APP Plus Quality Measure Set modifications
• CMS finalized, with modification, the addition of seven new quality measures.
• CMS finalized the removal of 10 quality measures.
• CMS finalized substantive changes to 66 quality measures.
• CMS finalized six new episode-based cost measures and revised two existing episode-based cost measures.
• CMS is revising cost measure scoring methodology to assess clinician cost of care more appropriately. 
• CMS is removing improvement activity weighting and streamlining the reporting requirements for the performance category.

 

CMS is finalizing a new HCPCS add-on code to describe the intensity and complexity inherent to hospital inpatient or observation care, associated with a confirmed or suspected infectious disease, performed by a practitioner with specialized training in infectious diseases. The new HCPCS add-on code describes service elements, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment.

 

For CY 2025, CMS is finalizing a policy to broaden the applicability of the transfer of care modifier 54, for all 90-day global surgical packages (global packages), in any case when a practitioner expects to furnish only the surgical procedure portion of the 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 finalizing a new add-on code, HCPCS code G0559, for post-operative care services furnished by a practitioner other than the one who performed the surgical procedure (or another practitioner in the same group practice). This add-on code will more appropriately reflect the time and resources involved in these post-operative follow-up visits by practitioners who were not involved in furnishing the surgical procedure.

 

For CY 2025, CMS is finalizing amendments to the certification regulations to lessen the administrative burden for therapists (PTs, OTs, and speech-language pathologists (SLPs)) and physician/NPPs. These changes will provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification, in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation.

 

CMS is expanding coverage for CRC screening to include computed tomography colonography (CTC). CMS is adding Medicare covered blood-based biomarker CRC screening tests as part of the continuum of screening. CMS is also revising the regulation text to clarify that CRC screening frequency limitations do not apply to the follow-on screening colonoscopy in the context of “complete CRC screening.” 

 

 

 

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