Positive aspects of the final schedule include the G2211 code being used with same-day wellness visits and revision of telehealth to include audio-only communications
Nov. 22, 2024 (ACP) -- The final 2025 Medicare Physician Fee Schedule was released on Nov. 1, and ACP is pleased with several aspects of the fee schedule that could help strengthen primary care and drive equity and innovation.
ACP is especially pleased that the Centers for Medicare & Medicaid Services has finalized its proposal to allow payment of the office/outpatient (O/O) evaluation and management (E/M) visit complexity add-on code (Healthcare Common Procedure Coding System [HCPCS] code G2211) when the O/O E/M base code (CPT 99202-99205, 99211-99215) is reported by the same practitioner on the same day as an annual wellness visit, vaccine administration or any Medicare Part B preventive service, according to Brian Outland, ACP director of regulatory affairs. “This is definitely a win for internal medicine and primary care,” said Shari Erickson, ACP chief advocacy officer and senior vice president of governmental affairs and public policy.
“However, as CMS continues to refine its policy for payment of the O/O E/M visits complexity add-on code, ACP urges the agency to allow this code to be reported across all sites of service, including Home or Residence E/M services that meet the requirements of the add-on code,” Outland noted.
As he explained, “the principles that resulted in the appropriate recognition of the additional work and other resources related to a longitudinal care relationship in primary care or the care of a patient with a serious or complex condition are identical whether the care is in the office or the patient's home. Patients receiving care in the home are typically underserved and more dependent on continuity relationships. In principle and policy, these vulnerable beneficiaries should be supported by accurate payment to those who serve them.”
ACP is also pleased that CMS is revising the definition of telehealth to include audio-only communications.
“Expanding the definition to include audio-only phone calls will be especially beneficial to these patients who are elderly, lack access to advanced technology or do not have adequate access to broadband services,” Outland said. “ACP is particularly encouraged by how audio-only technology can positively impact behavioral and mental health among rural and underserved populations, as these populations are more likely to have access to audio-only technology than audio-video technology. We believe that physicians should continue to be empowered to determine when services can be furnished via audio-only formats.”
For calendar year 2025, CMS is implementing a new enhanced program for Advanced Primary Care Management (APCM) services aimed at relieving administrative burdens and more appropriately reimbursing physicians caring for patients with complex medical and social needs, helping to promote health equity. Physicians and other practitioners who use an advanced primary care model could bill for APCM services for a beneficiary when they intend to be responsible for all the patient's primary care and are the continuing focal point for all needed healthcare services. The proposed APCM services would (1) incorporate elements of several existing care management and communication technology-based codes into a bundle, (2) remove some of the more burdensome elements of billing and coding the individual service elements, (3) not be time-based, but rather based on a set of service elements and practice level requirements, (4) be stratified into three levels to reflect patient medical complexity and social complexity, and (5) be billed monthly. This proposed set of APCM services would be described by three new HCPCS G-codes:
- G0556, approximate national non-facility rate $15 – Patients with one or fewer chronic conditions; proposed work RVU of 0.25
- G0557, approximate national non-facility rate $50 – Patients with two or more chronic conditions; proposed work RVU of 0.77
- G0558, approximate national non-facility rate $110 – Patients with two or more chronic conditions and who are qualified Medicare beneficiaries; proposed work RVU of 1.67
CMS increased the valuation of HCPCS code G0556 to reflect the equivalent of three units of 99490 or 60 minutes of work time in Chronic Care Management (CCM) equivalents divided over 12 months, or approximately $15 per month.
“CMS recognizes that this is a relatively modest increase in valuation for G0556 and may revisit the valuation of this and other APCM codes in future rulemaking,” Outland said.
Overall, the 2025 fee schedule is the shortest in some time and did not change much from the earlier proposal.
ACP continues to have concerns about how potential confusion over existing codes – CCM and Transitional Care Management – may be used along with the new APCM codes and lead to possible administrative burdens, Outland explained.
“There is also the concern of cost-sharing for APCM services -- that cost-sharing could hinder beneficiary consent and uptake,” he said. “There is a need to work with Congress and the Advisory Committee on Immunization Practices on having APCM services be considered preventive and exempt from cost-sharing, pointing out the difficulties in educating beneficiaries about these services when they are not typically present during their provision.”
CMS acknowledged the support and concerns, emphasizing that the new codes aim to improve payment accuracy, Outland said, though they do not currently meet criteria for preventive services.
“CMS also expressed openness to further discussions and future rulemaking with the American Medical Association's Current Procedural Terminology Panel to refine the system,” Outland said.
Meanwhile, ACP remains deeply concerned about the proposed 2.8 percent payment cut for 2025 due to a decrease in the conversion factor to remain budget-neutral. “This payment cut is proposed on top of a payment cut for 2024 that was only partially fixed through congressional action, a fix that will expire at the end of this calendar year,” Outland said. “Congress must step in to stop the payment cut from going into effect. ACP has been calling on Congress for several years to take long-term action to fix this issue.”
Back to the November 22, 2024 issue of ACP Advocate