CMS CY 2025 Proposed Physician Fee Schedule Rule

CMS CY 2025 Proposed Physician Fee Schedule Rule

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2025. The proposed rule would strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, and maintain telehealth flexibilities. The 60-day comment period for the CY 2025 PFS proposed rule (CMS-1807-P) ends September 9, 2024.

CMS is proposing several impactful changes to behavioral health services in this year’s rule. CMS is proposing new payments for practitioners who are assisting people at high risk of suicide or overdose, including separate payment for safety planning interventions and post-discharge follow-up contacts. CMS is also proposing new payment and coding for use of digital tools that further support the delivery of specific behavioral health treatments, and also new coding and payment to make it easier for practitioners to consult behavioral health specialists. For Opioid Treatment Programs (OTPs), this rule also proposes new codes for FDA-approved medications for the treatment of Opioid Use Disorder (OUD) and known or suspected opioid overdose, increased telecommunication flexibilities for periodic assessments and methadone treatment initiation, and an increase in payment for intake activities to provide more comprehensive services for the treatment of OUD, including assessing for unmet health-related social needs, harm reduction intervention needs, and recovery support service needs.

Behavioral Health

For CY 2025, CMS is proposing establishing separate coding and payment under the PFS describing safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose. Specifically, they are proposing to create an add-on G-code that would be billed along with an E/M visit or psychotherapy service when safety planning interventions are personally performed by the billing practitioner in a variety of settings. Additionally, they are proposing to create a monthly billing code that requires specific protocols in furnishing post-discharge follow-up contacts that are performed in conjunction with a discharge from the emergency department for a crisis encounter, as a bundled service describing four calls in a month.

To further support access to psychotherapy, they are also proposing Medicare payment for digital mental health treatment devices furnished incident to or integral to professional behavioral health services used in conjunction with ongoing behavioral health care treatment under a behavioral health treatment plan of care. They are proposing to create three new HCPCS codes and would monitor how digital mental health treatment devices are used as part of overall behavioral health care. They are also proposing to create six G codes to be billed by practitioners in specialties whose covered services are limited by statute to services for the diagnosis and treatment of mental illness (including Clinical Psychologists, Clinical Social Workers, Marriage and Family Therapists, and Mental Health Counselors) to mirror current interprofessional consultation CPT codes used by practitioners who are eligible to bill E/M visits. If finalized, this would allow for better integration of behavioral health specialty treatment into primary care and other settings.

Lastly, they are seeking comment on whether coding and payment for Intensive Outpatient Program (IOP) services under the PFS would be appropriate services in additional settings (such as Certified Community Behavioral Health Clinics (CCBHCs)), as well as seeking comment on facilities that offer crisis stabilization services and non-emergent, urgent care.

Telehealth

During the COVID-19 public health emergency, CMS took action to expand access to telehealth services to ensure people with Medicare could continue to access health care. Proposals in this year’s rule would allow CMS to maintain some important, but limited, flexibilities where possible and reflect CMS’ goal to maintain and expand the scope of and access to telehealth services where appropriate. For example, these proposals would continue to permit certain practitioners to provide virtual direct supervision to auxiliary personnel when required. However, absent Congressional action, beginning January 1, 2025, the statutory restrictions on geography, site of service, and practitioner type that existed prior to the COVID-19 PHE will go back into effect. After that date, people with Medicare will need to be in a rural area and a medical facility to receive non-behavioral health services via Medicare telehealth.

Additionally, CMS is proposing that beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.

They are proposing that, through CY 2025, they will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home.

CMS is proposing, for a certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising practitioner, 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. They are specifically proposing that the physician or supervising practitioner may provide such virtual direct supervision for services furnished incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of office or other outpatient visit for the evaluation and management of an established patient who may not require the presence of a physician or other qualified health care professional. For all other services furnished under the direct supervision of the supervising physician or other practitioner, they are proposing to continue to define “immediate availability” to include real-time audio and visual interactive telecommunications technology only through December 31, 2025.

Opioid Treatment Programs (OTPs)

CMS is proposing several telecommunication technology flexibilities for opioid use disorder (OUD) treatment services furnished by OTPs, as long as the use of these technologies are permitted under the applicable SAMHSA and DEA requirements at the time the services are furnished, and all other applicable requirements are met. First, CMS is proposing to make permanent the current flexibility for furnishing periodic assessments via audio-only telecommunications beginning January 1, 2025 so long as all other applicable requirements are met. Second, CMS is proposing to 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 (using HCPCS code G2076) if the OTP determines that an adequate evaluation of the patient can be accomplished via an audio-visual telehealth platform.

CMS is also proposing payment increases in response to recent regulatory reforms for OUD treatment finalized by SAMHSA at 42 CFR part 8. Specifically, CMS is proposing to update payment for intake activities furnished by OTPs to include payment for social determinants of health risk assessments to adequately reflect additional effort for OTPs to identify a patient’s unmet health-related social needs or the need and interest for harm reduction interventions and recovery support services that are critical to the treatment of an OUD. CMS is also requesting information to understand how OTPs currently coordinate care and make referrals to community-based organizations that address unmet health-related social needs, provide harm reduction services, and/or offer recovery support services.

CMS is also proposing to establish payment for new opioid agonist and antagonist medications approved by the FDA. First, CMS is proposing a new add-on code for a nalmefene hydrochloride nasal spray product (Opvee®) indicated for the emergency treatment of known or suspected opioid overdose. Second, CMS is proposing payment for a new injectable buprenorphine product (Brixadi®) via a new weekly bundled payment code for the weekly formulation of Brixadi®, and by including payment for the monthly formulation of Brixadi® into the existing code for monthly injectable buprenorphine.

Lastly, CMS is clarifying a billing requirement that OTPs must append an OUD diagnosis code on claims for OUD treatment services, consistent with Medicare coverage and payment provisions under the Social Security Act.

Comment Request

CMS is accepting comments on this rule in its entirety; however, they are asked for specific feedback for CY 2025, related to the newly implemented Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment to engage interested parties on additional policy refinements for CMS to consider in future rulemaking. They are requesting information on other factors to consider, such as other types of auxiliary personnel (including clinical social workers) and other certification and/or training requirements that are not adequately captured in current coding and payment for these services and how to improve utilization in rural areas. They are also seeking comments about how these codes are being furnished in conjunction with community-based organizations.