CMS Proposes 2025 Medicare Physician Payment Rates & Other Policies

On July 10th,  CMS released the calendar year (CY) 2025 Medicare Physician Fee Schedule (MPFS) proposed rule. CMS proposed a CY 2025 conversion factor of $32.3562, a decrease of approximately 2.8% from the CY 2024 conversion factor of $33.2875. This decrease is due to a combination of the expiration of the 2.93% bump provided by Congress for CY 2024 payments plus a positive budget neutrality adjustment of 0.05% triggered by CY 2025 policies. Because the cut is driven by the expiration of 2024's Congressional assistance, Congress is the entity that must act to prevent the cut in CY 2025.

In addition to the proposed conversion factor cut, Congress will also be called to action to further delay a sequestration of Medicare payments due to the "pay-as-you-go" (PAYGO) federal congressional budgetary rule that requires an across-the-board reduction in federal spending when legislation is passed but not fully paid for. Because of previously large spending bills, a 4% Medicare spending cut was expected under this provision, but Congress delayed it until 2025. Without Congressional action, this cut of the Medicare portion of payment for services provided to Medicare beneficiaries will further affect payments.

To illustrate, this table shows the general Medicare physician fee schedule payment rates for several electrophysiology services in 2024, the payment rates in 2025 under the proposed conversion factor cut, and the payments in 2025 if PAYGO sequestration goes into effect on top of the conversion factor cut.  (Note that these estimates do not include other payment adjustments (e.g., MIPS or geographic adjustments).

Note: These figures include the ongoing Budget Control Act sequestration cut of 2% 

HRS is working on behalf of its members to underscore the importance of electrophysiology services to both the Administration and Congress and to bring attention to the issues these annual cuts place on the ability of Medicare beneficiaries to access electrophysiology services.

In addition to the general payment update, CMS also addressed several other policies relevant to electrophysiologists:

• Remote Services:
  • Telehealth Services: CMS proposes to maintain its general payment policy for telehealth services in CY 2025. CMS declined AMA recommendations to replace the current coding and billing approach (where "in person" codes are billed with a telehealth place-of-service (POS) code when furnished via telehealth) with a set of codes that more directly described the delivery of a telemedicine service. CMS will continue to maintain a list of approved Medicare telehealth services. CMS notes that unless Congress acts by the end of 2024 to extend the COVID-era telehealth flexibilities, the ability to deliver telehealth services to Medicare patients located in their homes will narrow to a more limited set of services (e.g., behavioral services provided via telehealth).
  • Virtual Check-ins: CMS is proposing to replace the G-code it created for "Brief virtual-check ins" (G2012) with a new AMA replacement code for the service, accepting the placeholder code 9X091.
• Cardiovascular Risk Assessment and Risk Management Services
  To build on the findings from the Innovation Center's Million Hearts® model, CMS is introducing two new G-codes for the PFS: one for use of an atherosclerosis cardiovascular disease (ASCVD) risk assessment tool (GCDRA) and one for ASCVD risk management services (GCDRM). In reviewing the Million Hearts® model, the Innovation Center attributed the success of the model "to increased rates of cardiovascular risk assessment, discussion of cardiovascular risk by participants' clinicians, and use of appropriate medications to reduce cardiovascular risk (for example, aspirin and statins)." CMS proposes total non-facility RVUs for GCDRA of 0.57; and CMS proposes total non-facility RVUs for GCDRM of 0.48.
• Global Surgical Payments. CMS continues to express concern about the accuracy of the values of global procedure payments. In this rule, CMS proposals are aimed at scenarios in which CMS believes that a practitioner different from the physician who performed the 90-day global procedure is furnishing post-operative visits to a Medicare beneficiary.
  • Transfer-of-Care Modifiers: CMS proposes to broaden the scope of the current "transfer of care" modifiers (Modifiers ~54, ~55, and ~56) for globals to instances beyond which there is formal, documented transfer of care (as is the case under current policy) to also include when there is "an informal, non-documented but expected, transfer of care."
  • Post-op Visit Add-on Code: CMS proposes to introduce a new E/M add-on code for practitioners (who are neither the proceduralist who conducted the surgery or anyone in their practice nor a proceduralist of the same specialty) delivering an E/M service outside a formal transfer of care when that service is related to the procedure. The descriptor for this new add on code is proposed as follows:

GPOC1 (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 a different specialty than the practitioner who performed the procedure, within the 090-day global period of the procedure(s), once per 090-day global period, when there has not been a formal transfer of care and requires the following elements, when possible and applicable:

• Reading available surgical note to understand the relative success of the procedure, the anatomy that was affected, and potential complications that could have arisen due to the unique circumstances of the patient's operation.
• Research the procedure to determine expected post-operative course and potential complications (in the case of doing a post-op for a procedure outside the specialty).
• Evaluate and physically examine the patient to determine whether the post-operative course is progressing appropriately.
• Communicate with the practitioner who performed the procedure if any questions or concerns arise. (List separately in addition to office/outpatient evaluation and management visit, new or established))
• Quality Payment Program (QPP)
  • Key proposals related to the Merit-Based Incentive Payment System (MIPS) include:
    • Continuing to expand upon the MIPS Value Pathway (MVP) framework by proposing new MVPs, making revisions to existing MVPs (including the Advancing Care for Heart Disease MVP), and seeking feedback on clinician readiness for a potential plan to sunset traditional MIPS and fully transition to MVPs in 2029;
    • Maintaining the 75-point MIPS performance threshold for 2025, which is the minimum number of points needed to avoid a penalty, recognizing the need for consistency in the program and additional time for more recent data not impacted by the COVID-19 pandemic to become available.
    • Proposing changes to MIPS specialty sets, which are recommended sets of quality measures that CMS has identified as most relevant to a specialty. CMS proposes changes to the Cardiology Specialty Set, as well as the Electrophysiology Specialty Set. For the latter, CMS is proposing to make substantive change to measure #393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision to clarify the definition of a new device.
    • Proposing to remove improvement activity weights and to reduce the improvement activity attestation requirement in both traditional MIPS and MVPs.
    • Proposing a new improvement activity titled, "Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk" which would allow clinicians to receive credit for implementing a standardized, evidence-based cardiovascular disease risk assessment and care management plan in their practices.
    • Revisions to MIPS scoring methodologies to allow for more successful participation among clinicians reporting specific high-performing quality measures subject to the topped-out scoring cap and to enhance cost measure scores, which have traditionally been lower than quality measures scores.
  • Qualifying Participants (QPs) in Advanced Alternative Payment Models (APMs)
    • QPs will continue to be exempt from MIPS in 2025. While QPs will receive a 1.88% APM incentive payment in 2026 (based on eligibility in 2024), QPs will no longer be eligible for an APM incentive payment starting in 2025. However, starting in 2026, CMS will apply two separate conversion factor updates under the physician fee schedule—one for QPs (0.75%) and one for all non-QP eligible clinicians, including MIPS participants (0.25%). Also, beginning next year, the thresholds to qualify as a QP will increase, making it more challenging for clinicians to qualify for this track of the QPP. Since these are policies required by statute, Congressional action would be required to extend the APM incentive payment and freeze eligibility thresholds at their current level.

For additional details, view the full CY 2025 MPFS proposed rule:

• CMS Press Release
• CMS CY 2025 MPFS Fact Sheet
• CMS CY 2025 QPP Fact Sheet
• CMS CY 2025 Proposed and Modified MVP Guide
• CMS CY 2025 MSSP ACO Fact Sheet

HRS will submit comments by the September 9, 2024, deadline.