CMS makes changes to behavioral health, new codes, and cuts to rates in 2025 MPFS final rule

Organizations must prepare for a slew of new codes and billing updates for Part B payment, according to the 2025 Medicare Physician Fee Schedule (MPFS) final rule. The final rule, released November 1, details CMS’ numerous changes to payment rates, billable services, telehealth rules, and other services.

CMS finalized a 2.83% reduction to the conversion factor. Overall payments under the MPFS will be reduced by 2.93% in 2025. This includes the expiration of the temporary 2.93% increase in payment for 2024 and an estimated 0.02% adjustment to account for changes in work relative value units for certain services.

Medicare Shared Savings Program

CMS finalized its proposal to establish a prepaid shared savings plan for accountable care organizations (ACO) that have a good track record of earned savings under the Medicare Shared Savings Program (MSSP). This plan will offer eligible ACOs advance payments of earned shared savings that the ACOs will use to make investments that will aid their beneficiaries. Participating ACOs must spend half of the advance payments on direct beneficiary services that don’t receive traditional Medicare payments.

Other changes to the MSSP include changes to the methodologies used for financial calculations, including changes to the methodology used to calculate the impact of improper payments. Several of these provisions reflect other changes CMS finalized in a separate rule, published in September, addressing the effect of anomalous and suspect billing practices on the MSSP.

For more information on MSSP changes in the 2025 MPFS final rule, see CMS’ fact sheet.

Telehealth

With the remaining COVID-19 waivers set to expire at the end of this year, CMS finalized the extension of certain flexibilities. CMS will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home for 2025. The agency will also continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for 2025.

CMS also finalized its proposal 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.

Other telehealth changes for 2025 include:

• 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
• Addition of services to the Medicare Telehealth Services list on a provisional basis (including caregiver training services) and a permanent basis (including PrEP counseling and safety planning interventions)
• Continuing to allow teaching physicians to have a virtual presence for purposes of billing under certain circumstances
• Deletion of HCPCS code G2012 (brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional) and adoption of Current Procedural Terminology (CPT®) code 98016 (brief communication technology-based service [e.g., virtual check-in] by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion)

G2211 changes

CMS finalized its proposal 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).

Starting in 2025, G2211 may be reported on the same day as an annual wellness visit, the administration of a vaccine, or any Medicare Part B preventive service.

Transfer of care modifier

Starting January 1, 2025, practitioners must 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, according to the final rule. CMS also finalized its proposal to create a new add-on HCPCS code, GPOC1, for post-operative care services.

Behavioral health

2025 will see a slew of changes to behavioral health services, according to the final rule.

CMS finalized the following three new codes for digital mental health treatment (DMHT):

G0553 (first 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month

G0554 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment

(DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month)

G0552 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan)

The therapeutic codes G0553 and G0554 may be billed only when there is ongoing use of the DMHT device, and G0554 should be listed separately from G0553, according to the final rule.

The following conditions must be met to report G0552:

• The DMHT device must have been previously approved by the FDA
• Supplying the device must be incident-to the billing practitioner’s professional services in association with ongoing treatment under a plan of care by the billing practitioner

For G0552 to be payable, the billing practitioner must incur a cost to acquire and furnish the DMHT device.

In addition to DMHT, CMS made several other changes to coverage, coding, and reimbursement for behavioral health services, including coverage of HCPCS codes G0546-G0551 for certain interprofessional consultation services. The agency also finalized new HCPCS codes for safety planning interventions (G0560) and follow-up after a behavioral health crisis (G0544).

More new codes, services

The final rule details a slew of other new codes, covered services, and requirements including changes to covered dental and oral health services, advanced primary care management, therapy supervision, quality reporting, and more. Most provisions will go into effect January 1, 2025.

Revenue integrity professionals should read the final rule carefully, focusing on the sections that will directly affect their jobs and workflows. Make note of new codes and code updates. Ensure systems are updated and tested before the end of the year. Meet with colleagues in other departments to discuss and coordinate education and schedule time to talk to clinical leaders about whether they plan to offer any newly covered services.