HRS Reports on CMS 2025 Medicare Physician Fee Schedule and Outpatient Hospital/ASC Final Rules
On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) published the final rules for the calendar year (CY) 2025 Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.
As HRS does every year, the Society submitted comments to CMS on the proposed rules in September. A summary of HRS proposed rule comments and CMS final rule actions related to those comments appears below, with greater detail in the text summaries that follow.
HRS Comments to CMS and CMS Actions for CY2025
| ISSUE | HRS COMMENTS TO CMS | CMS ACTION |
|---|---|---|
| Use of EP Code 21 | HRS urged CMS to regularly report specialty-specific data and projections with the inclusion of specialty designation code 21- cardiac electrophysiology. | CMS did not include Cardiac EP in TABLE 110: CY 2025 PFS Estimated Impact on Total Allowed Charges by Specialty. |
| Conversion Factor | HRS strongly urged CMS not to cut the conversion factor and to work with Congress to develop a permanent solution to stabilize the Medicare physician payment system for CY 2025 and beyond. | CMS cut the conversion factor by 2.83%. |
| Telehealth | HRS encouraged CMS to finalize the policy allowing broader telehealth services but noted the limited applicability on the ability of EPs to provide telehealth services to Medicare beneficiaries if Congress does not extend the waivers that allow patients to receive services furnished via telehealth in their homes past the December 31, 2024 waiver sunset. | Telehealth services were broadened, but the waivers are still set to sunset on December 31, 2024. See “Medicare Telehealth Services” discussion for more detail. |
| Global Surgery Payment Accuracy | HRS expressed concern regarding CMS’ proposed policy to expand the use of transfer-of-care modifiers to an “informal, non-documented but expected transfer-of-care” for post-op care (Modifier 55) and pre-op care (Modifier 56). | CMS only expanded the use of Modifier 54 for surgical care and did not expand for Modifiers 55 and 56. See section on Global Surgical Payments below for details. |
| Post-op Care Services Add-on Code GPOCI | HRS expressed extreme concern that this add-on code is poorly defined, subject to abuse, and likely to generate claims data that CMS will misappropriate to suggest that physicians who did not perform the global procedure are performing post-op visits. For all of the reasons listed above, HRS opposed the implementation of GPOC1. | CMS finalized the new E/M add-on code for practitioners delivering an E/M service outside a formal transfer of care. See section on Global Surgical Payments for details. |
| Coverage for Ablations in ASC’s | HRS met with CMS and sent a detailed comment letter to explain that cardiac catheter ablations can be safely performed on an ambulatory basis in appropriately selected Medicare patients as adjudicated by physician judgment (with case selection determined by patient clinical and social considerations, physician experience, and facility support). | Cardiac catheter ablations were not included on the covered procedure list for ASC’s. |
| MACRA / MIPS | HRS supported the CMS proposal to maintain the threshold to avoid a penalty under the MIPS program of up to nine percent at 75 points for the CY 2025 performance year/2027 payment year. CMS proposed substantive changes to measure #393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision. HRS supported the update to the measure instructions. HRS urged CMS to address the ongoing lack of specialty-focused APMs through more comprehensive and focused solutions that support better coordination of care and more accurate assessments of value. | The threshold was maintained at 75 points. The proposed changes to measure #393 were approved. See section on MPFS Quality Payment Program (QPP) Updates for details. |
MPFS Payment and Policy Updates
The conversion factor (CF) for CY 2025 is set at $32.3465, a 2.83% reduction from the CY 2024 CF. The final CY 2025 CF reflects a 0.02 percent positive budget neutrality adjustment as required by law; the 0.00 percent update adjustment factor specified under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA); and removal of the temporary 2.93% payment increase for services furnished from March 9, 2024, through December 31, 2024, authorized in the Consolidated Appropriations Act, 2024.
In the Society’s comment letter on the proposed rule, HRS urged CMS to work with Congress to develop a permanent solution to stabilize the Medicare physician payment system for CY 2025 and beyond. HRS will continue to advocate strongly for physician payment reform.
CMS will continue to pay for Office and Outpatient E/M as telehealth services under its current authority, bearing in mind that geographic and site of service restrictions that were in place prior to the COVID-19 Public Health Emergency (PHE) will again be in effect starting January 1, 2025, unless Congress intervenes. HRS urged CMS to work with Congress to ensure that the flexibilities are permanently extended beyond the December 31, 2024, deadline. Following are telehealth highlights from the final rule.
• Audio-only: CMS will allow use of audio-only communication technology to meet the definition of “telecommunications system” for the purpose of furnishing telehealth to patients in their homes, when certain conditions are met. This is a win for HRS members. Use of audio-only communication technology will eliminate barriers for Medicare patients who do not consent to, or are not capable of, use of video technology.;
• Reporting of Distant Site Address: CMS finalized its proposal that, through 2025, it will continue to permit practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home.
• Direct Supervision via Virtual Presence:
• CMS finalized its proposal to allow direct supervision via virtual presence using audio/video real-time communications technology on a permanent basis, but only when: (1) the service is provided by auxiliary personnel employed by the billing practitioner and working under their direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’; or (2) the service is an Office or other Outpatient Evaluation/Management visit for an established patient that may not require the presence of a physician or other qualified healthcare practitioner (i.e., CPT 99211).
• For all other services, CMS finalized its proposal to continue to allow for direct supervision via virtual presence using real-time audio and visual interactive telecommunications technology through 2025.
• Teaching Physician Supervision via Virtual Presence: CMS finalized its proposal to continue its current policy to allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, but only when the service is furnished virtually.
• Telemedicine E/M Codes: As proposed, CMS did not adopt 16 of 17 new telemedicine codes established by the AMA CPT Editorial Panel.
• Virtual Check-Ins: CMS finalized its proposal to adopt CPT code 98016 for virtual check-ins in lieu of HCPCS G2012.
In response to the proposed rule, HRS questioned CMS’ proposal to modify current transfer-of-care modifiers (-54, -55 and -56) for global surgical packages to an “informal, non-documented but expected transfer-of-care.
In the final rule, CMS broadened the policy for “transfer of care” and use of Modifier -54 (Surgical Care Only). Under this change, for services with 90-day global periods, Modifier -54 would be applied in 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, expected transfer of care. CMS will not, however, change the current policy for Modifiers -55 and -56; and
CMS finalized the new E/M add-on code for practitioners (who are neither the surgeon who conducted the surgery or anyone in their practice) delivering an E/M service outside a formal transfer of care when that service is related to the procedure with the modification that physicians in the same specialty as the surgeon can bill the add-on code (as long as they are outside the surgeon’s group practice).
CMS revisited its finalized policy that G2211 is not payable when the Office and Outpatient E/M (O/O E/M) is reported with Modifier -25. CMS also finalized its proposal to provide an exception to the Modifier -25 billing prohibition for G2211 "to allow payment of the O/O E/M visit complexity add-on code when the O/O E/M base code reported by the same practitioner on the same day as an annual wellness visit, vaccine administration, or any Medicare Part B preventive service furnished in the office or outpatient setting."
CMS confirmed that this policy includes the "Welcome to Medicare" visit. CMS said it might also consider expanding use of G2211 to services other than Office and Outpatient E/M visits where the practitioner is the "continuing focal point."
• Medicare Economic Index (MEI). As proposed, CMS will again delay incorporating the 2017-based MEI in fee schedule rate-setting for CY 2025 as it awaits data from the AMA Physician Practice Information Survey (PPIS) and considers other data sources.
• Clinical Labor. CY 2025 represents the final year of the 4-year transition to the updated clinical labor wage inputs.
• Updating PE Data Collection and Methods. CMS acknowledged stakeholder feedback and will consider it in future rulemaking.
Outpatient Hospital and ASC Updates
On November 1st, CMS published the final rule for the CY 2025 Ambulatory Surgery Center (ASC) covered procedures list (CPL). Again, CMS denied coverage for cardiac catheter ablations in the ASC setting, despite evidence showing the procedures are safe and effective for same-day discharge in appropriately selected Medicare patients.
CMS received requests to add 74 procedures for the CY 2025 CPL, but did not consider many as safe to be performed in the ASC setting. Specifically, CMS stated many of the cardiovascular codes (cardiac ablations, cardioversion, EP studies and procedures, and echocardiography) have associated inpatient admissions and require active medical monitoring and care at midnight following the procedure.
CMS further stated that cardioversion and echocardiography codes are non-surgical procedures and would not qualify for the ASC CPL, and most of the ancillary codes are not integral to a covered surgical procedure on the ASC CPL. However, CMS failed to specify which cardiovascular codes apply to the exclusionary criteria.
HRS disagrees with CMS' decision and will prepare comments in response to the final rule and seek further clarification on the general standards and exclusionary criteria for the ASC CPL. The ASC denial underscores the importance of HRS forming Heart Rhythm Advocates, a new initiative that will allow the Society to engage in more substantial lobbying and political efforts on behalf of both patients and members. HRS will continue to push for coverage of ablations in ASCs.
MPFS Quality Payment Program (QPP) Updates
For MVPs, CMS finalized the following changes.
• While CMS reiterated its intention to move to full MVP adoption and to sunset traditional MIPS in the future, it did not mention 2029 as a potential date, as it did in the proposed rule.
• CMS removed the requirement for MVP Participants to select one population health measure at the time of MVP registration and will instead use the highest score of all available population health measures, as proposed, and made minor changes to the Advancing Care for Heart Disease MIPS Value Pathway.
• CMS finalized its proposal to remove high/medium weights from improvement activities in MVPs; MVP participants will only be required to attest to 1 activity for full credit, rather than 2, starting in 2025.
For traditional MIPS, CMS finalized the following performance category changes.
• Scoring
• CMS will maintain the 75-point performance threshold. This is a win for HRS. The Society supported this proposal and appreciates CMS for taking into account the need for program consistency to allow clinicians to gain more experience with cost measure scoring.
• CMS will allow clinicians to request reweighting of a category when data are inaccessible and unable to be submitted due to reasons outside control of clinician who delegated data submission to a 3rd party intermediary (e.g., registry).
• Quality
• Finalized proposal to maintain 75% data completeness threshold for 2 additional years— the 2027 and 2028 performance periods.
• Minor changes to the Cardiology Specialty Set, as well as the Electrophysiology Specialty Set. For the latter, CMS finalized a 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. HRS supported this proposal and urged CMS to finalize it clarify the definition of a new device.
• Finalized revised methodology for scoring topped out quality measures in specialty sets with limited measures. CMS will remove the 7-point cap for 16 measures, as proposed, and subject them instead to a defined topped out measure benchmark. CMS did not finalize its proposal to omit the possibility of earning 9-9.9 points under this benchmark since it would unnecessarily penalize clinicians facing limited measure choice.
• Finalized a complex organization adjustment to account for organizational complexities facing APM Entities and virtual groups when reporting eCQMs. CMS will add one measure achievement point for each submitted eCQM (subject to a cap) if data completeness and case minimum requirements are met by the APM Entity or virtual group.
• For multiple quality (and improvement activity) submissions from different organizations (e.g., a registry and the practice administrator) for the same reporting option, CMS codified its existing process to score each submission and use the highest scoring measures. For multiple submissions received from the same organization (e.g., two practice administrators) for the same reporting option, CMS will score the most recent submission.
• Improvement Activities
• Finalized proposal to remove the activity weights and reduce number required to report to 2 (versus 2-4 for non-small practices) and 1 for small practices/rural/non-patient facing starting in 2025.
• Finalized new IA: IA_PM_XX titled "Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk," which would allow MIPS eligible clinicians to receive credit for implementing a standardized, evidence-based cardiovascular disease risk assessment and care management plan in their practices
• Promoting Interoperability
• Multiple submissions: Beginning with the 2024 performance year, for multiple data submissions received, CMS will use the highest score.
• Cost
• Modified existing ST-Elevation Myocardial Infarction (STEMI) PCI (acute inpatient medical condition) cost measure
• Finalized revisions to the cost measure scoring methodology to measure cost more appropriately in relation to national averages (based on standard deviations from median), starting with the 2024 performance period. Expected to raise cost scores for most/not negatively impact clinicians whose average costs are around median.
• APM Performance Pathway (APP)
• CMS finalized, with a revised timeline, a new expanded quality measure set (APP Plus) that would be optional for clinicians in MIPS APMs, but required for Shared Savings Program ACOs. CMS will incrementally add measures to the APP Plus set, culminating in 11 required measures by the 2028 performance period.
• CMS will continue to offer the existing APP quality measure set for non-Shared Savings Program MIPS APM participants.
• Alternative Payment Models (APMs)
• As required under statute, starting with payment year 2025 (based on 2023 eligibility), Qualifying Participants (QPs) in Advanced APMs will receive a lump-sum APM Incentive Payment equal to 3.5% payment of their estimated aggregate paid amounts for covered professional services furnished during CY 2024 (down from 5%). In payment year 2026 (based on 2024 eligibility), this incentive payment drops to 1.88%. Also beginning in payment year 2026, CMS will apply two separate PFS conversion factor updates—one for QPs (0.75) and one for all non-QP eligible clinicians (0.25)
• Also under statute, the thresholds to achieve QP status beginning in the 2025 QP performance period will increase to 75% (from 50%) for the payment amount method, and 50% (from 35%) for the patient count method.
• CMS did not finalize its proposal to use claims for all covered professional services to identify attribution-eligible beneficiaries for all Advanced APMs. CMS will continue to rely on the use of E/M claims, which encourages APM Entities to prefer primary care practitioners over specialists on their Participation Lists since they contribute more significantly to achieving QP status. CMS has determined there is more work to be done in this area. While the proposed approach might make improvements to QP determinations, it could also result in low QP scores in certain Advanced APMs, particularly where an Advanced APM is focused on a limited set of services, diseases, or conditions.
• RFI on Building Upon the MVP Framework to Improve Ambulatory Specialty Care
• CMS provided no discussion about comments received in response to this Innovation Center RFI on a potential future model for specialists in ambulatory settings that would leverage the MVP framework other than noting that it would consider comments during future rulemaking and work related to the design of a future ambulatory specialty model.
• Shared Savings Program. CMS finalized several updates to the Medicare Shared Savings Program (SSP), including to:
• Revise the definition of primary care services used for assignment in the SSP to include several new services, including advanced primary care management services, cardiovascular risk assessment and risk management services, caregiver training services, and more. CMS did not finalize its proposal to include certain interprofessional consultation services as part of the definition of primary care services.
• Require SSP accountable care organizations (ACOs) to report the APP Plus quality measure set.
• Establish a prepaid shared savings option for certain eligible ACOs.
• Incorporate a health equity benchmark adjustment, among other updates to the SSP financial methodology; and
• Modify beneficiary notification requirements to reduce burden.