7 changes in the 2025 Medicare Physician Fee Schedule Final Rule that benefit practices
Here are 7 Medicare reimbursement opportunities in 2025 that can boost practices’ revenue and patient care quality.
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At a Glance
- The CY 2025 Medicare Physician Fee Schedule Final Rule introduces 7 significant changes for medical practices, including new billing opportunities for caregiver training, expanded colorectal cancer screenings, and enhanced vaccine coverage for Hepatitis B.
- Providers will gain additional reimbursement options for telehealth services, cardiovascular risk assessment, and more complex evaluation and management visits, with new codes allowing billing for services like virtual care and technology-based patient management.
- These changes aim to improve patient care, increase revenue opportunities, and support more comprehensive healthcare services, despite an anticipated 2.8% physician payment cut.
The calendar year (CY) 2025 Medicare Physician Fee Schedule Final Rule published on November 1, 2024 and includes the highly anticipated (and dreaded) 2.8% physician payment cut that begins on January 1, 2025. However, it also includes many positive changes that introduce new revenue prospects as well as opportunities to improve patient care.
This article highlights 7 key changes that medical practices and their partnering medical billing companies should keep in mind.
Here are also some additional resources about the rule to refer to:
- The Centers for Medicare & Medicaid Services' (CMS) CY 2025 Medicare Physician Fee Schedule Final Rule
- Additional files and supporting documentation from CMS
- American Medical Association's summary of the rule
1. Billing allowed for time spent training caregivers
Starting January 1, 2025, CMS will pay for 3 new Healthcare Common Procedure Coding System (HCPCS) codes (i.e., G0541-G0543) denoting caregiver training for direct care services and supports to help caregivers care for individuals with an ongoing condition or illness. This includes but is not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control. The patient is not present for these services, and providers may give the services to caregivers in person or via telehealth in 2025.
“Starting January 1, 2025, CMS will pay for 3 new Healthcare Common Procedure Coding System codes denoting caregiver training for direct care services and supports to help caregivers care for individuals with an ongoing condition or illness.”
Providers may also give services to individual caregivers one-on-one or to multiple sets of caregivers in a group setting. However, when providing these services to individual caregivers, there is a 30-minute minimum time requirement for billing. In the CY 2025 physician fee schedule, G0541 has a work relative value unit (wRVU) of 1.00. For G0542, it’s 0.54, and for G0543, it’s 0.23. Note that there are also 2 new codes for caregiver behavior management and modification training (G0539 and G0540) with wRVUs of 1.00 and 0.54, respectively.
2. Expanded colorectal cancer screenings to improve cancer detection
Starting January 1, 2025, CMS will expand coverage of colorectal cancer (CRC) screening to include computed tomography colonography. The agency will also add blood-based biomarker CRC screening tests to the continuum of screening. In addition, there will be no CRC screening frequency limitations to follow-up screening colonoscopy in the context of complete CRC screening.
3. Expanded vaccine coverage to help prevent Hepatitis B
Starting January 1, 2025, CMS will expand coverage of the hepatitis B vaccine to include people who haven’t previously received a completed hepatitis B vaccine series or whose vaccine history is unknown.
4. Telehealth billing requirements easier to satisfy
Starting January 1, 2025, when a patient cannot use or does not consent to use video technology, providers can still bill telehealth with an interactive telecommunications system. However, if you are a distant site provider, you must still have audio-video capabilities.
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5. Earlier detection of cardiovascular risk
Starting January 1, 2025, CMS will pay for atherosclerotic cardiovascular disease (ASCVD) risk assessment and risk management services for patients without current cardiovascular disease or a history of heart attack or stroke when those patients have at least one predisposing condition that puts them at risk for future ASCVD. These include obesity, family history of cardiovascular disease, history of high blood pressure, history of high cholesterol, history of smoking/alcohol/drug use, pre-diabetes, or diabetes.
“Starting January 1, 2025, CMS will pay for atherosclerotic cardiovascular disease risk assessment and risk management services for patients without current cardiovascular disease or a history of heart attack or stroke when those patients have at least one predisposing condition that puts them at risk for future ASCVD.”
Providers will need to perform an evidence-based ASCVD assessment during an evaluation and management (E/M) visit and spend 5-15 minutes with the patient not more than once every 12 months. Risk management includes medication management, blood pressure management, cholesterol management, and smoking cessation for patients with intermediate, medium, or high risk based on the assessment. In the CY 2025 physician fee schedule, the risk assessment code, G0537, has a wRVU of 0.18. The risk management code, G0538, has a wRVU of 0.18 as well.
6. Increased opportunities to bill E/M visit complexity
Starting January 1, 2025, providers will be able to report E/M complexity add-on code G2211 with a base E/M code even when you perform an annual wellness visit, administer a vaccine, or provide any Medicare Part B preventive service on the same day. In the CY 2025 physician fee schedule, G2211 has a wRVU of 0.33.
7. Addition of virtual care and other technology to address patients’ needs
Starting January 1, 2025, providers can report 3 new codes for advanced primary care management (G0556-G0558) that combine elements of the existing chronic care management and principal care management codes with technology-based services like virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults. The good news? These are not time-based codes. In the CY 2025 physician fee schedule, G0556 has a wRVU of 0.25, G0557 has a wRVU of 0.77, and G0558 has a wRVU of 1.67.
Looking ahead
Many of these changes help providers not only provide better patient care but also receive payment for providing that care. Leveraging opportunities outlined in the CY 2025 Medicare Physician Fee Schedule Final Rule will be important in the year ahead and beyond. While you’re at it, be sure to review 2025 CPT code changes as well. Medical practices that embrace new services to enhance patient engagement and improve outcomes will be most successful in the long run.
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