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September 19, 2024 – Comments on the calendar year (CY) 2025 physician fee schedule (PFS) proposed reg were due last week. As a reminder, this is the major annual reg that affects payments for physician and other clinicians under Medicare. Now, the Centers for Medicare & Medicaid Services (CMS) must review the comments and issue a final reg on or around November 1, 2024 – 60 days before the start of the new year.
Stakeholders submit thousands of comments on this massive reg every year. However, the number of comments received on this year’s reg is much lower than average – and significantly lower than last year’s total. Last year, CMS received more than 22,000 comments, but this year, CMS only received 12,028 (a 45% reduction). I’m not entirely sure what accounts for this drop (guesses are welcome), but it’s noteworthy regardless!
With that insight out of the way, below are 10 major PFS comments that I have identified. And be sure to check out our Physician Fee Schedule Payment System Dashboard for an interactive look at how payments for services of interest have changed across years and how much their services are getting paid across localities.
Provider groups expressed universal concern and disappointment about the proposed 2.8% cut to the CY 2025 PFS conversion factor (CF). They pointed to the fact that this is the fifth straight year in which the CF has been reduced, despite the costs of practicing medicine continuing to grow each year, as measured by the Medicare Economic Index (MEI). The MEI is estimated to grow by 3.6% in CY 2025. Some commenters pointed to a striking statistic: the CY 2025 CF is 12% less than the CF was in 1998 (the first year that CMS established a single CF) even though costs have increased by 92% over the same time period. These groups urged CMS to work with Congress to enact permanent Medicare physician payment reform.
As discussed in a previous Regs & Eggs blog post, CMS proposed a global surgical policy that would trigger a positive budget neutrality adjustment, tempering the reduction to the PFS. Regs & Eggs previously noted that if CMS ultimately decided not to finalize this policy, the final cut to the CF could actually be higher than the proposed 2.8% reduction. Stakeholders had many comments on this proposal, with some questioning the validity and appropriateness of CMS’s proposed expansion of the transfer of care modifier and new post-operative care add-on code (GPOC1). It remains to be seen how CMS may adjust the proposal to address stakeholder input. Because of this policy’s impact on the CF, we will carefully monitor this issue when the final reg is issued.
While there are established processes for vetting new and modifying current PFS codes, the American Medical Association (AMA) Relative Value Scale Update Committee (RUC) and Current Procedural Terminology (CPT®) processes, CMS can also unilaterally add new codes to the PFS. These codes, which don’t go through the CPT or RUC processes, are called G-codes. While CMS has periodically added new G-codes throughout the years, CMS proposed an abnormally high number in this year’s reg. Some commenters expressed concern about these new codes generally. Stakeholders believe that some of the new codes overlap with existing CPT codes and that CMS should use the existing CPT and RUC processes when adding or modifying codes. In the views of some provider groups, not only does this potential duplication between G-codes and existing CPT codes cause confusion about what codes to bill, it might also increase administrative burden. G-codes are only used in the Medicare fee-for-service program. While Medicare Advantage and private payer plans can use these codes, they typically don’t. Thus, if CMS finalizes these new G-codes, providers would have to establish separate billing practices for Medicare fee-for-service beneficiaries if they wish to use the new codes. Providers stated that they would much rather have, to the extent possible, unified billing practices across different payers.
One proposed set of G-codes that garnered particular interest was the advanced primary care codes (GPCM1, GPCM2, and GPCM3). While stakeholders appreciated CMS’s continued emphasis on promoting primary care and improving care coordination and follow-up care for patients with complex and chronic conditions, some noted that elements of the proposed new codes overlap with existing care management CPT codes, including chronic care management, transitional care management, and principal care management, and therefore they questioned the need for establishing this new code set.
Speaking of G-codes, in the CY 2024 PFS final reg, CMS finalized a new office/outpatient evaluation and management (E/M) visit complexity add-on code, G2211. CMS established requirements for when the code could be billed, including restricting the use of the code when the underlying office/outpatient E/M visit is reported with CPT modifier -25, which denotes a significant, separately identifiable office/outpatient E/M visit by the same provider on the same day as a procedure or other service. Some commenters expressed concern about this restriction because some preventive services such as the annual wellness visit or a preventive vaccine are often provided on the same day as a separately identifiable office/outpatient E/M visit, billed with modifier -25. After considering these concerns, CMS proposed in this year’s reg to allow payment of the add-on code when the office/outpatient E/M base code is 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. This policy would be effective in CY 2025.
Provider groups whose clinicians use these codes were generally supportive of the proposal. However, others expressed concern about CMS’s proposal to expand the code before clinicians have had ample experience using it appropriately and before CMS has discussed utilization of the data (CMS won’t have utilization data until the CY 2026 PFS rulemaking cycle). When CMS proposed the code last year, many groups expressed concerns about the need for the code (as there are CPT codes already in existence that measure the time and resources it takes to provide care to complex patients), the lack of clarity of when to bill for the code, and CMS’s failure to go through the normal CPT process to create the code. These groups expressed the same concerns this year, and although CMS recently released guidance, clinicians need time and experience to truly understand when it is appropriate to bill the code. Thus, the groups urged the agency not to expand the circumstances in which the code can be billed at this time.
CMS also received many comments on the use of telehealth. Most provider groups and telehealth stakeholders supported the continued flexibility that CMS proposed to provide. This flexibility includes keeping the telehealth codes that were added to the newly added “Provisional” Medicare Telehealth List through CY 2025 and extending the direct supervision flexibilities another year. However, stakeholders had mixed reactions regarding CMS’s proposal not to pay for the 16 new audio-visual and audio-only telemedicine E/M codes created by the AMA CPT Editorial Panel. CMS argued in the proposed reg that the new telemedicine E/M codes are no different than the office/outpatient E/M codes, which are already permanently on the Medicare Telehealth List. CMS also questioned its authority to create standalone telemedicine codes that would not be subject the Medicare telehealth restrictions specified in the Medicare statute (Section 1834(m) of the Social Security Act). While some stakeholders agreed with the premise of CMS’s argument that these new CPT codes are duplicative of the office/outpatient E/M codes, others argued that CMS has the statutory authority to recognize and pay for the new CPT codes and that the codes are not the same as the existing office/outpatient E/M services.
Many provider groups expressed significant concerns about the direction CMS is heading with the Quality Payment Program, especially with regard to the Merit-Based Incentive Payment System (MIPS) Value Pathways (MVP) framework. Groups questioned CMS’s overall approach to transitioning the MIPS program to MVPs over time. CMS sought comment on, but did not propose, a sunset date of 2029 for traditional MIPS, at which time MVPs would become mandatory instead of voluntary. Most commenters urged CMS to keep participation in MVPs voluntary and not to sunset traditional MIPS. Some also expressed concerns about CMS’s idea to double down on MVPs by using this pathway as the method by which specialists could participate in alternative payment models (APMs). These stakeholders argued that CMS must first focus on making fundamental improvements to MVPs, including eliminating population-based measures and significantly modifying the subgroup reporting option (which becomes mandatory in 2026), before MVPs can be used as the foundation for any sort of APM. Commenters stated that instead of using this approach to encourage specialists to participate in MVPs, CMS should create more APMs that are directly targeted at specialists, reduce barriers to APM participation, and work with Congress to expand the financial incentives for participating in an Advanced APM (extending the Advanced APM bonus).
Commenters also expressed various concerns about CMS’s proposal to make six new MVPs available for reporting beginning with the CY 2025 performance period:
Stakeholders had many additional comments on MIPS:
While there was overarching support for many of the core MIPS proposals (with some notable exceptions), stakeholders generally felt that the proposals would not fundamentally address the major issues that they believe to be present within the program. As described in this Regs & Eggs blog post, some stakeholders have expressed concern that MIPS is not achieving its intended purpose of improving quality and reducing costs. In many stakeholders’ view, in order for MIPS to achieve its intended purpose, it has to be totally restructured – which could take congressional action to accomplish.
Stakeholders generally supported CMS’s proposals to enhance payment for dealing with patients in crisis situations. CMS proposed to establish a establish an add-on G-code, GSPI1, for safety planning interventions for patients with suicidal ideation or at risk of suicide or overdose. CMS also proposed an additional monthly code, GFCI1, to pay for follow-up phone calls to patients discharged from the emergency department for behavioral health or other crisis encounters. Stakeholders generally agreed that while the emergency department functions as our nation’s safety net, it is not the best place to handle individuals with mental health crises. Therefore, they supported CMS’s efforts to think through alternative sites of care for these individuals. Stakeholders provided input on CMS’s request for comments on how community-based crisis stabilization centers can provide immediate access to voluntary and/or involuntary care, without the need for a referral. They also weighed in on the types of services these centers provide and bill, and the impact they can have on underserved areas.
In recent years, CMS has been looking to expand cases where Medicare can cover dental care. Medicare is restricted from covering dental services outright but can cover these services when they are “inextricably linked” to other clinical services that are covered by Medicare. In this year’s reg, CMS proposed to add certain dental services associated with dialysis services for beneficiaries with end-stage renal disease to the list of clinical scenarios under which fee-for-service Medicare payment may be made. CMS also sought comment on the potential connection between dental services and covered services used in the treatment of diabetes, sickle cell disease, hemophilia, and autoimmune diseases receiving immunosuppressive therapies.
Commenters were generally supportive of efforts to expand the list of clinical scenarios in which dental services may be covered. However, stakeholders expressed concern about the “high bar” of having to prove that a dental service is “inextricably linked to other covered medical services.” For example, some stakeholders noted that covering dental services would greatly benefit patients with diabetes, but struggled to delineate an “inextricably linked” connection. Stakeholders also stated that if CMS were to significantly expand coverage of dental services through the PFS, the budget neutrality requirement could impact (i.e., lower) payments for other services.
Because of the current statutory and regulatory restrictions on coverage of dental services, some stakeholders urged CMS to work with Congress to further expand dental coverage and establish separate reimbursement for these services.
As in previous years, CMS proposed to use the PFS to implement changes to the Medicare Shared Savings Program (MSSP), the main accountable care organization (ACO) program in Medicare. Many proposals in this year’s reg garnered responses:
In the reg, CMS requested comment on how to appropriately pay for services delivered in various settings. One such request focused on urgent care centers, which CMS believes could reduce unnecessary emergency department visits by serving as a better place to address non-emergent urgent care needs. Commenters supported urgent care centers’ important role in treating patients and encouraged CMS to explore ways to promote their use. However, some commenters urged CMS to be more careful about how it refers to “unnecessary” emergency department visits, pointing to certain laws, such as the Prudent Layperson Standard, that protect patients’ fundamental right to seek emergency care when they think they are experiencing a medical emergency, even if they don’t know for sure. Commenters asked CMS to provide more education to Medicare beneficiaries about when they should seek emergency treatment, their right to do so, and when another setting such as an urgent care center may be appropriate to address their healthcare needs.
Other notable proposals and comment solicitations that stakeholders generally supported included the following:
Some providers also submitted comments on a nontraditional PFS proposal related to overpayments. CMS proposed to revise repayment deadlines for overpayments under Medicare Parts A and B by modifying the standard 60-day repayment deadline and allowing it to be suspended for up to 180 days. During this suspension period, providers that identified an overpayment on at least one patient record would be able to conduct an investigation to potentially identify other affected claims and calculate the aggregate amount of the overpayment. While groups generally supported the proposal, they asked for clarification from CMS to ensure that there would be enough time for providers to organize funds and make payments once an aggregate overpayment amount was determined.
I’m still poring over different stakeholder reactions and expect that more nuanced trends and themes could emerge. The possibility for congressional action also could further shape both the outcome of CMS’s rulemaking and the ultimate impact on physician and clinician practices. I would love to hear your thoughts on these reactions to the reg and key issues you’re seeing and tracking.
Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.
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