On July 10, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued its calendar year 2025 Medicare Physician Fee Schedule (“MPFS”) proposed rule (“Proposed Rule”), to implement certain payment updates effective January 1, 2025. Several major proposals are summarized below and the fact sheet accompanying this Proposed Rule may be found here.
Telehealth Services Paid Under MPFS
If finalized, the Proposed Rule would allow for an “interactive telecommunication system” to also include two-way, real-time audio-only communication technology for any telehealth service furnished to beneficiaries in their homes if the distant site physician or practitioner is capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology. A modifier would have to be appended to the claims for these services in order to verify conditions have been met. Additionally, the proposal would continue to permit the distant site practitioner to use their enrolled practice location instead of their home address when providing telehealth services from their home.
CMS also proposes to permanently adopt a definition of “direct supervision” that allows the physician or supervising practitioner to provide such supervision through real-time audio and visual interactive telecommunications for services typically performed by auxiliary personnel on an incident-to basis. For all other services furnished under direct supervision, CMS proposes to extend this definition of “immediate availability” only through December 31, 2025.
Advanced Primary Care Management Services
CMS proposes to adopt new Healthcare Common Procedure Coding System (“HCPCS”) codes for newly defined advanced primary care management (“APCM”) services based on patient needs. Practitioners who use an advanced primary care model of delivery could bill for these APCM services when they are the continuing focal point for all needed health care services and responsible for all the patient’s primary care services. With this model, the Proposed Rule seeks to incorporate elements of existing care management and communication technology-based services (“CTBS”) that reflect essential elements of the delivery of advanced primary care for payment under PFS beginning in 2025.
Opioid Treatment Programs
CMS proposes several telecommunication technology flexibilities for opioid use disorder treatment services furnished, so long as the technologies are permitted by the Substance Abuse and Mental Health Administration and Drug Enforcement Administration at the time they are furnished. This includes a proposal to make permanent the current flexibility for furnishing periodic assessments via audio-only telecommunications and if the opioid treatment program (“OTP”) determines that an audio-visual telehealth platform is adequate to evaluate a patient. Additionally, the Proposed Rule would allow the OTP intake add-on code to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with methadone under HCPCS code G2076. CMS is also proposing payment changes, including updated payment for intake activities to include payment for social determinants of health risk assessments and establishing payment for new opioid agonist and antagonist medications.
Proposals Related to Rural Health Clinics and Federally Qualified Health Centers
Through the Proposed Rule, CMS proposes Rural Health Clinics (“RHCs”) and Federally Qualified Health Centers (“FQHCs”) to report individual Current Procedural Terminology and HCPCS codes that describe care coordination instead of the single HCPCS code G0511 currently used by these providers. Additionally, the Proposed Rule seeks to provide a different rate of payment for Intensive Outpatient Services provided in the RHC or FQHC when four or more services are rendered per day compared to the current payment amount based on three services. CMS also proposes to allow payment, on a temporary basis, for non-behavioral health visits furnished via CTBS through HCPCS code G2025. Lastly, the Proposed Rule proposes changes to RHC and FQHC Conditions of Coverages to explicitly require RHCs and FQHCs to provide primary care services rather than being “primarily engaged” in furnishing such services.
Practical Takeaways
- The Proposed Rule also including proposed changes to the Medicare Shared Savings Program (“Shared Savings Program”) to further advance the Administration’s Medicare initiatives. Hall Render plans to publish a separate alert on the proposed updates to the Shared Savings Program.
- The rule finalizing these proposals will likely be published by the end of November 2024.
For more information on the Proposed Rule, please contact:
- Regan Tankersley at (317) 977-1445 or rtankersley@hallrender.com;
- Lauren Hulls at (317) 977-1467 or lhulls@hallrender.com;
- Lori Wink at (414) 721-0456 or lwink@hallrender.com;
- Lisa Lucido at (248) 457-7812 or llucido@hallrender.com;
- Julie Mitchell at (317) 429-3643 or jmitchell@hallrender.com;
- Kaitlin Nucci at (248) 457-7838 or knucci@hallrender.com; or
- Your primary Hall Render contact.
Special thanks to summer associate, Wyatt Poer, for his assistance with this article.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
