Medicare CY25 Physician Fee Schedule – Final Rule

On November 1, the Centers for Medicare & Medicaid Services (CMS) released the Final Calendar Year (CY) 2025 Physician Fee Schedule (PFS), outlining important Medicare policy updates for the coming year (fact sheet; press release). As in previous years, the PFS contains multiple proposals affecting telehealth policy. Many temporary federal telehealth waivers in Medicare are set to expire this year, and their extension would require congressional action. However, CMS made adjustments within its authority to mitigate the effects of these expirations if Congress does not act to extend statutory flexibilities further.

Telehealth - Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services. These include geographic and location restrictions on where the services are provided, and limitations on the scope of practitioners who can provide Medicare telehealth services. After that date, people with Medicare generally will need to be located in a medical facility in a rural area to receive most Medicare telehealth services, with a notable exception for behavioral health telehealth services which can continue to be provided in the patient’s home. However, the in-person visit requirements will go into effect starting 1/1/25. Medicare beneficiaries must have an in-person visit with their behavioral health provider no more than six months before their initial telehealth appointment and annually thereafter.

CMS is finalizing that beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time, audio-only communication technology for any Medicare 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. To streamline claims for these services, practitioners should use modifier “93” for general audio-only services. CMS clarified that claims for telehealth services billed with place of service 10 (“telehealth provided in patient’s home”) will continue to be paid at the non-facility PFS rate for CY 2025 and beyond.

Behavioral Health Services – CMS finalized a new standalone code, G0560, to pay for safety planning interventions (SPI) for patients in crisis in a variety of settings, including those with suicidal ideation or at risk of suicide or overdose, which can be reported in 20-minute increments. SPI can include assisting the patient in following a personalized safety plan, utilizing family members and friends to help resolve the crisis, contacting mental health professionals, and others. The SPI code is also being added to the telehealth list. An additional monthly code, G0544, is a monthly code intended to support four follow-up telephone calls after discharge from the emergency department or certain other settings for a crisis encounter. CMS adopted three codes, G0552-G0554, for digital mental health treatment devices furnished under a behavioral health treatment plan of care. It also adopted six HCPCS codes, G0546-G0551, that parallel the existing CPT codes for interprofessional consultations for use by certain nonphysician mental health professionals (including clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors) who CMS says cannot report the CPT codes with the goal of better integrating behavioral health treatment into primary care and other settings

Direct Supervision — In the CY 2024 PFS final rule, CMS extended the definition of the term “direct supervision” to allow practitioner supervisions through real-time audio and video interactive telecommunications through December 31, 2024. While CMS acknowledges the benefit of this flexibility, the agency is exercising caution and prioritizing patient safety by further extending this flexibility on a temporary basis through December 31, 2025.

OTPs - CMS clarifies that all claims submitted to Medicare under the OTP benefit must include an OUD diagnosis, sharing its intent to issue additional guidance on attaching diagnostic codes to claims. CMS is finalizing its proposals to: (1) make permanent the current flexibility that allows periodic assessments to be furnished through audio-only telecommunications when video is not available; and (2) allow the OTP intake add-on code to be furnished through audio-visual telecommunications for initiation of treatment with methadone. CMS is also adding payment for SDOH risk assessments and coordinated care, referrals to community-based organizations, peer recovery support services, and payment for new FDA-approved medications. More information for OTPs is available here.