2025 MPFS proposed rule: New codes and modifiers, major changes to telehealth and MSSP in the works

Organizations could see a flood of new codes along with significant changes to the Medicare Shared Savings Program (MSSP) and coverage of telehealth services, according the 2025 Medicare Physician Fee Schedule (MPFS) proposed rule. Released July 10, the proposed rule outlines major plans for changes to Part B reimbursement, coding, and more.

Conversion factor

For 2025, CMS is proposing to reduce the conversion factor by 2.8% compared to 2024. This is lower than the 3.36% CMS proposed for 2024 and the 3.39% it finalized in the 2024 MPFS final rule.

MSSP

CMS is proposing a prepaid shared savings plan for accountable care organizations (ACO) that have a good track record of earned savings. This plan would offer eligible ACOs advance payments of earned shared savings that the ACOs could use to make investments that would aid their beneficiaries, according to the proposed rule. ACOs would have to spend half of the advance payments on direct beneficiary services that don’t receive traditional Medicare payments.

Other proposals relating to MSSPs include a new Quality Payment Program scoring method and a new performance assessment benchmark focused on health equity.

Telehealth changes

Many of the telehealth flexibilities that were introduced via public health emergency (PHE) waivers during the COVID-19 pandemic will be expiring, and extension or permanent implementation is up to Congress. However, CMS is considering some changes and plans to maintain some flexibilities.

CMS is proposing to expand the audio-only telehealth option to any patient who is at home during the service if the distant site physician or practitioner is able to use an “interactive telecommunications system” that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication, but the patient is not capable of, or does not consent to, the use of video technology.

Under current Medicare rules, the audio-only exception would be limited to encounters related to behavioral healthcare if the COVID-19 PHE waivers were not in effect. CMS also plans to keep looser direct supervision requirements for audio-visual telehealth services in certain circumstances through 2025 and will allow providers who perform telehealth services from home to continue to report services under their office address. However, the statutory restrictions on location, site of service, and practitioner type that were in place prior to the COVID-19 PHE will go back into effect January 1, 2025, unless Congress takes action, according to the proposed rule.

Other telehealth proposals include:

• Addition of several services to the Medicare Telehealth Services list on a provisional basis including caregiver training services
• Continuing to permit the distant site practitioner to use their practice location instead of their home address when providing telehealth services from their home
• Continuing the suspension of frequency limitations for subsequent inpatient and nursing facility visits and critical care consultations
• Permanently adopting a definition of direct supervision that, for certain services, allows the physician or supervising practitioner to supervise through interactive real-time audio and video technology

See the proposed rule for additional telehealth proposals.

Evaluation and management visits

CMS is proposing to expand opportunities to report Healthcare Common Procedure Coding System (HCPCS) code G2211(visit complexity inherent to evaluation and management [E/M] associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition).

Specifically, CMS is proposing to allow G2211 to be reported on the same day as an annual wellness visit, the administration of a vaccine, or any Medicare Part B preventive service. The agency is proposing the change in response to complaints that current restrictions interfere with the way patients receive treatment, even though CMS reviewed the available data and stated that its analysis did not demonstrate that the current policy is disruptive to care.

Dental and oral health

CMS is proposing to add to the list of clinical scenarios under which Part B payment may be made for dental and oral health services. These would include dental or oral examination in inpatient or outpatient setting prior to covered dialysis services for end-stage renal disease (ESRD) patients and diagnostic and treatment services of an oral infection prior to, or at the same time as dialysis services for ESRD patients.

CMS is also proposing to require modifier -KX on claims for dental services inextricably linked to covered medical procedures. Additionally, the agency is proposing to require diagnosis code 837D on the dental claim format.

CMS is also requesting feedback and information on clinical scenarios that could be added to the list in future rulemaking.

Surgical package codes and modifiers

CMS is proposing that practitioners report transfer of care modifiers -54, -55, and -56 when they provide only the pre-operative, intraoperative, or post-operative portions of a 90-day global procedure. In addition, the agency is proposing a new add-on code, GPOC1, for post-operative care services. CMS believes the new add-on code would more accurately reflect the time and resources needed for these visits, including the involvement of practitioners who did not furnish the surgical procedure.

New services and codes

CMS is proposing a slew of new codes for services including advanced primary care management services and atherosclerotic cardiovascular disease risk assessment and risk management services.

CMS is also proposing a new add-on HCPCS code that would account for the added complexity of care involved in treating patients with infectious diseases. The proposed add-on code, GIDXX (visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment), to account for the added complexity of care), would be reportable for cases involving hospital inpatients or outpatients in observation.

Other proposals

CMS is mulling numerous other proposals, including new codes and requirements for behavioral health, supervision policy for physical therapists and occupational therapists, opioid treatment programs, caregiver training, and more. See the proposed rule, and the accompanying fact sheet, for details on specific proposals.

Revenue integrity professionals should carefully read the proposed rule. Focus on the proposals that would directly impact your organization, community, department, and specific job duties. Discuss the proposals with your revenue integrity colleagues as well as your peers in other departments who may be impacted.

Commenting on proposed rules is a crucial way to advocate for improvements that will benefit your community and protect the Medicare Trust Fund. Consider commenting on one or more proposals and responding to CMS’ direct requests for feedback in the proposed rule by the September 9 deadline. For guidance on how to write and submit an impactful comment, use NAHRI’s white paper Advocacy in Action: Commenting on Proposed Rules.