Key Highlights from the Proposed 2025 Medicare Physician Fee Schedule: What Providers Need to Know

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) unveiled the 2025 Proposed Medicare Physician Fee Schedule. This new rule included several policy proposals that could significantly impact the healthcare sector. Below are some key highlights regarding remote monitoring, telehealth and care management services that providers should be aware of:

Conversion Factor Adjustment

For 2025, CMS is proposing a decrease of the conversion factor by 2.8%, from $33.29 in 2024 to $32.36 in 2025. This adjustment reflects the expiration of a 2.93% payment increase from 2024, a 0.00% update under the Medicare Access and CHIP Reauthorization Act, and a 0.05% budget-neutrality adjustment​.

Advanced Primary Care Management Services (APCM)

In an effort to move towards value-based care, CMS is proposing coding and reimbursement for a new set of Advanced Primary Care Management (APCM) services. The proposed services would incorporate elements of existing care management services and communication technology-based services into a bundle of services, including Chronic Care Management (CCM), Principal Care Management (PCM), and Transitional Care Management (TCM).

The new APCM codes will be stratified into three levels based on the number of chronic conditions and Qualified Medicare Beneficiary enrollment, reflecting patients’ medical and social complexity. These HCPCS codes (GPCM1, GPCM2, and GPCM3) will emphasize comprehensive and accessible care management services tailored to patients’ preferred care delivery methods rather than the time clinicians spend on specific activities.

There are 13 required elements for the APCM code sets, many of which practitioners providing Chronic Care Management (CCM) and Principal Care Management (PCM) services may already implement. However, CMS expects that practices capable of meeting all 13 required elements will be able to provide APCM to most, if not all, of their patients.

It is also important to note that unlike CCM and PCM services, the APCM codes are not time based. This means care management services that do not meet the 20- or 30-minute requirements for CCM and PCM would be billable under APCM.

Remote Monitoring

CMS is proposing a reduction in reimbursement for remote therapeutic monitoring (RTM), but there was no mention of changes for remote patient monitoring (RPM).

Additionally, CMS did not address the 16-day data reporting requirement for billing RPM and RTM codes.

Rural Health Clinics and Federally Qualified Health Clinics

For 2025, CMS proposes several changes to how Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) report care coordination services to better align payment with other entities providing this type of care. Specifically, CMS proposes that RHCs and FQHCs use individual CPT and HCPCS codes for care coordination services, such as chronic care management and remote monitoring, instead of the single HCPCS code G0511.

CMS is also proposing the adoption of the new Advanced Primary Care Model (APCM) codes if they are finalized.

In addition, CMS proposes allowing RHCs and FQHCs to conduct telehealth visits using audio-only services and to waive the in-person visit requirement for telemental health services through the end of 2025.

Telehealth Services

CMS is proposing flexibility for virtual supervision and the use of telehealth in teaching settings will also continue.

CMS is delaying the requirement that telehealth providers report their home addresses on Medicare documentation until the end of 2025.

CMS is proposing extending certain telehealth waivers through 2025, including those allowing RHCs and FQHCs to bill for telehealth services.

CMS is exploring permanent changes for telehealth; however, many pandemic-era waivers will require Congressional action to be extended beyond 2024.

Digital Therapeutics

For 2025, CMS is proposing three new codes, GBMT1-3, for the supply of a digital mental health treatment device and for physician time spent interacting with the patient regarding the device. The proposal would allow providers to receive payment for FDA-cleared devices that leverage software to provide behavioral health therapies.

Looking Ahead

Many of the changes in the 2025 Proposed Medicare Physician Fee Schedule offer new opportunities for more comprehensive care management services and expanded flexibilities for virtual care. Providers should carefully review the proposed rule to understand its impact on reimbursement rates and eligibility criteria.

The proposed rule is scheduled to be published in the Federal Register on July 31, and comments are due to CMS by Sept. 9, 2024. For additional information, please see the CMS press release, and the 2025 Physician Fee Schedule proposed rule fact sheet.

This article is for informational purposes only and should not be taken as billing or legal advice.