CMS has introduced its Medicare Fee Schedule Lookup* for the CY 2024-2025 and made a lot of changes in the codes and payment structures for many medical services. Now, you might have many questions in your mind about how this new Medicare physician fee schedule will affect my practice revenue, right? Don’t worry; this article shares a complete question-and-answer guide by specialty-specific certified coding and billing experts. It answers all your questions about the new Medicare Fee Schedule Lookup and how it will affect your coding and reimbursements in the coming calendar year.
1. How will the proposed rule affect my reimbursement rates?
The new 2025 Medicare Physician Fee Schedule Lookup suggests updates to the conversion factor while affecting reimbursement rates across various specialties. Understanding these changes is vital to calculating payments using the updated Medicare fee schedule lookup. The conversion factor is being adjusted, which will slightly reduce or increase payments depending on service categories.
2. What changes are proposed for evaluation and management (E/M) services?
E/M services are seeing notable updates, including more streamlined billing processes and updates to split/shared services guidelines. The goal is to make E/M coding easier for providers and increase accuracy in billing. For detailed information, use the Medicare physician fee schedule lookup to find specific rates.
3. Are there new telehealth policy updates?
Yes, telehealth services that expanded during the COVID-19 PHE will continue to be available temporarily through 2025, allowing more flexibility in service delivery. Providers should keep an eye on telehealth-specific payment rules using Medicare payment rules to stay updated on future changes.
4. How will split/shared services billing be impacted?
The proposal clarifies billing for split/shared services. In 2025, providers will have more guidance on how to bill appropriately for services that involve more than one healthcare professional, for example, in the form of a faculty or different ACOs. Reviewing Medicare physician fee schedule documents will help with compliance.
5. Are there changes to the rules for inpatient, nursing facility, or critical care consultations?
Yes, for 2025, Medicare Fee Schedule Lookup will continue suspending the usual frequency limits for follow-up inpatient and nursing facility visits, as well as critical care consultations.
6. Can we use audio-only technology for telehealth services?
Starting January 1, 2025, according to the Medicare Fee Schedule Lookup, audio-only communication is allowed if the patient can’t or doesn’t want to use video technology, but the doctor must have the capability for video.
7. Do I have to use my home address when providing telehealth from home?
No, you can keep using your current enrolled practice location instead of your home address through 2025.
8. Will there be changes to the Merit-Based Incentive Payment System?
Yes, MIPS scoring will continue to evolve in 2025, with adjustments to performance categories and data submission requirements. Providers should regularly check Medicare fee schedule lookup tools to ensure they comply with MIPS requirements and avoid penalties or low reimbursements.
9. Will there be hybrid payments for primary care services?
Yes, APCM services represent a step towards hybrid payments, combining both encounter-based and population-based payments to support long-term relationships between primary care providers and their patients.
10. Are there any new requirements for Advanced Alternative Payment Models?
New reporting requirements and incentives are being introduced for APMs to encourage more providers to participate in value based care. For accurate participation guidelines and payment rules, providers can consult the Medicare payment rules for APMs.
11. How will the conversion factor be adjusted for 2025?
The 2025 proposed rule includes a slight decrease in the conversion factor, which is critical for determining reimbursement rates across various services. Using the Medicare fee schedule lookup will give accurate calculations for different specialties.
12. How much are the average payment rates under the PFS expected to drop in 2025 compared to 2024?
The average payment rates are going to be reduced by 2.93% compared to those of 2024. This happens since required changes in regulations affect the size of the remunerations received by providers for their services.
13. Why is the 2025 conversion factor for the PFS decreasing?
The decrease is due to the expiration of a 2.93% payment increase that was applied in 2024. Without this boost and with no required increase for 2025, the conversion factor goes down.
14. What is the proposed 2025 PFS conversion factor in comparison to 2024?
Proposed for 2025, the conversion factor is $32.36, reflecting a 0.93 cents reduction from the 2024 factor of $33.29. This reflects the overall 2.80 percent decreased payment rates for 2025.
15. Are there changes to the Resource-Based Relative Value Scale?
Yes, adjustments to the RBRVS, including relative value units for certain procedures, are expected. These changes aim to ensure fair compensation based on the complexity and resources required for services. Providers should reference the Medicare fee schedule for the latest RVU values, or you can consult our experts.
16. What new services for caregiver training are included in the proposed Medicare fee schedule for 2025?
The proposal for 2025 includes new coding and payment for caregiver training in direct care services, such as wound care, infection control, and more.
17. Will chronic care management services be affected?
Chronic care management (CCM) services will continue to be supported, with potential increases in reimbursement rates to encourage more comprehensive care for chronic conditions. Providers should check the Medicare fee schedule 2025 for specific updates.
18. What are the new requirements for using transfer of care modifiers?
According to Medicare Fee Schedule Lookup, starting in 2025, practitioners must use the existing modifiers (-54, -55, -56) for all 90-day global surgery cases when they only provide part of the care, like pre-operative, surgery, or post-operative care, even in informal transfers.
19. What is the new GPOC1 code for post-operative care?
The GPOC1 add-on code is for post-operative care services. It compensates providers who weren’t involved in the surgery itself but handled post-operative visits, recognizing the time and resources these visits require.
20. What new codes are being proposed for behavioral safety planning?
For 2025, CMS is proposing a new add-on G-code that can be billed with an E/M visit or psychotherapy when the practitioner personally performs safety planning. There’s also a monthly billing code for follow-up calls after a crisis discharge from the ER.
21. Where I can find the list of all the new ICD-10-CM codes?
You can find all the new ICD-10-CM updates on the official CMS website, whereas the list of all the new ICD-10-CM codes is available here at Transcure.
22. Are there new proposals for digital mental health treatments?
Yes, Medicare is proposing payment for digital mental health treatment devices used as part of a behavioral health treatment plan. These devices would need to be related to ongoing care and treatment.
23. How will interprofessional consultations for behavioral health be billed?
CMS is proposing six new G-codes for specialists like Clinical Psychologists and Social Workers. These codes mirror current interprofessional consultation codes, making it easier for behavioral health to integrate with primary care.
24. Are there specific documentation requirements to qualify for the complexity add-on code G2211 when paired with preventive services like AWV or vaccine administration?
While the proposal mentions that you can use G2211 in these situations, you’ll likely need to document the additional complexity of the patient’s visit to justify using the code. Make sure you check the final guidelines for any specific documentation rules.
25. How will using code G2211 during O/O E/M visits impact my overall Medicare reimbursement for preventive services provided in the office or outpatient setting?
Adding G2211 to your O/O E/M visits when providing preventive services could increase your Medicare reimbursement, as the complexity add-on code is designed to account for the extra time and effort involved in managing more complex cases.
26. How will behavioral health services be impacted by the proposed rule of Medicare?
Behavioral health services, particularly related to psychiatric care and therapy, will see expanded coverage and new billing codes to reflect the growing importance of mental health. Use the Medicare fee schedule lookup to find appropriate codes for billing these services.
27. Are there any modifications to the payment for preventive services?
Preventive services continue to be prioritized, with potential updates in reimbursement rates to encourage providers to offer these vital services. Using the Medicare physician fee schedule lookup will provide the latest rates and guidelines for preventive services.
28. If I provide telehealth services from my home/currently enrolled, can I continue to use my practice location for Medicare billing instead of my home address through CY 2025?
Yes, you can keep using your currently enrolled location for billing, even if you’re providing telehealth from home throughout 2025. This helps protect your privacy and keeps things simple for billing purposes.
29. What does the proposed definition of “direct supervision” using real-time audio and video telecommunications mean for services provided by auxiliary personnel under my supervision?
This means you can provide direct supervision virtually for certain services that don’t require your physical presence, like those performed by staff under your supervision. Real-time audio and video would count as being “present,” allowing you to oversee care remotely.
30. Will virtual direct supervision be permanently allowed for certain services that don’t require my physical presence, and what are the specific services impacted by this change?
Yes, virtual supervision could become a permanent option for certain services, like office or outpatient visits where auxiliary staff are working under your supervision. This would allow you to manage these services without being on-site, as long as you’re available via real-time communication.
31. What are the rules for teaching physicians providing telehealth services in conjunction with residents, and how does virtual presence count toward the supervision requirement through 2025?
Through 2025, teaching physicians can meet the supervision requirement with a virtual presence, like in a three-way telehealth call with the patient, resident, and physician in different locations. This allows you to supervise and bill for services even when you’re not physically with the resident.
32. Is there any consideration for expanding the range of services under the primary care exception in the future, and how might this impact my ability to bill for these services?
Yes, Medicare is exploring the possibility of expanding services under the primary care exception. This could open up more opportunities to bill for services that might not currently fall under this exception, providing more flexibility in how you care for patients and get reimbursed.
33. What is the new add-on code for infectious diseases in Medicare Fee Schedule Lookup?
For 2025, a new HCPCS add-on code will be introduced for hospital inpatient or observation care for infectious diseases. It covers the extra complexity and intensity involved, like assessing disease transmission risk, doing public health investigations, and providing complex antimicrobial therapy.
34. What is the new supervision policy for PTs and OTs in private practice?
The proposed change allows physical therapists (PTs) and occupational therapists (OTs) in private practice to supervise their assistants (PTAs and OTAs) under general supervision, meaning they don’t have to be physically present during treatment.
35. How will physician supervision rules be updated in 2025’s Medicare Fee Schedule Lookup?
The 2025 proposal introduces more flexibility in physician supervision, particularly in rural settings or for telehealth services. These updates could reduce administrative burdens for providers.
36. What are the updates regarding care coordination services?
Care coordination services, including transitional care and chronic care management, are seeing more support and possibly increased payments. Providers should use the Medicare fee schedule to ensure they understand payment determinations for these services.
37. Will primary care services see any specific reimbursement changes?
Yes, primary care services will see updates that may affect the payment structure, especially for ongoing care and E/M visits. By reviewing the Medicare fee schedule lookup, primary care providers can determine their updated reimbursement rates.
38. How will services related to opioid use disorder be affected in 2025 Medicare Fee Schedule Lookup?
Treatment services for opioid use disorder will receive continued support with enhanced reimbursement for integrated behavioral health and treatment services. Providers can review the Medicare payment rules for opioid use disorders to ensure compliance and accurate billing.
39. What updates are there on the use of electronic health records (EHR) in Medicare Payment Schedule?
EHR updates will continue to be part of the QPP, and incentives remain for providers who integrate their systems according to Medicare’s guidelines. Check the Medicare fee schedule 2025 for detailed reporting requirements related to EHR use.
40. Will there be new incentive programs for rural health providers in the schedule?
Yes, the proposed rule includes enhanced support for rural health clinics, especially in the context of telehealth and preventive services. Providers can use the Medicare physician fee schedule lookup to explore incentives tailored for rural health settings.
41. How will this proposed Medicare rule impact the reporting requirements for 2025?
Reporting requirements will continue to focus on quality measures, patient outcomes, and cost-effective care. Providers should regularly review Medicare payment rules to stay informed of new reporting obligations.
42. Are there changes to the payment models for certain procedures?
Some procedures, especially in radiology and surgery, may see adjustments in payment models to reflect updated RBRVS and RVU values. Check the Medicare physician fee schedule for specifics on how procedures are billed in 2025.
43. Will the 2025 PPS final rule affect payments for radiology or imaging services?
Yes, radiology and imaging services are likely to experience payment adjustments. These changes are designed to reflect updates in resource use, making it essential for radiologists to review the Medicare fee schedule.
44. How will the global surgical packages be updated?
The global surgical packages may be reevaluated, with possible changes to how postoperative care is billed. Providers performing surgeries should monitor the Medicare fee schedule lookup for updates on global surgery reimbursement.
45. Are there any significant changes to telehealth originating sites?
Telehealth originating sites may continue to be expanded temporarily, offering more flexibility. Providers should use the Medicare fee schedule 2025 to determine the latest regulations and billing guidelines for telehealth services.
46. What are the new updates to the Medicare Shared Savings Program (MSSP)?
MSSP updates will continue to encourage accountable care organizations (ACOs) to focus on quality care and cost savings. The PPS final rule provides specific updates for ACOs.
47. Will the proposed rule affect hospital-based providers differently?
Hospital-based providers may experience different payment adjustments compared to outpatient or independent providers. Reviewing the Medicare physician fee schedule lookup will provide insights into specific payment structures for hospital-based services.
48. What is the new coding and payment structure for ASCVD risk assessment and management services in CY 2025, and how will it benefit my practice?
Starting in 2025, Medicare will roll out new codes and payment options for assessing and managing ASCVD risk. This means that when you identify patients at risk for cardiovascular issues and help them manage those risks, you’ll actually get paid for it!
49. Will there be additional payments for managing patients with multiple risk factors or comorbidities that complicate their CVD risk profile?
Yes, managing patients with multiple risk factors or comorbidities can qualify for additional payments according to 2025 Medicare Fee Schedule Lookup. This recognizes the extra effort involved in providing care for more complex cases, so it’s worth discussing with billing professionals. For more information, you can consult with our billing experts at Transcure.
50. What changes are being proposed for hepatitis B vaccine coverage under Medicare Part B?
The proposed changes in the Medicare Fee Schedule Lookup would expand coverage for hepatitis B vaccinations to include individuals who have never received a complete vaccination series or whose vaccination history is unknown. This aims to better protect Medicare beneficiaries from hepatitis B and work toward eliminating viral hepatitis as a health threat in the U.S.
51. Will a physician’s order be required for administering the hepatitis B vaccine?
No, if the proposed coverage expansion is finalized, a physician’s order will no longer be necessary for administering the hepatitis B vaccine under Part B Medicare Fee Schedule Lookup. This will make it easier for mass immunizers to bill for the vaccinations.
52. How will payment for the hepatitis B vaccine and its administration be structured?
The proposal suggests that payment for the hepatitis B vaccine and its administration will be made at 100% of reasonable cost in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). This payment will be separate from the payment methodologies currently used for these facilities, making the billing process smoother.
53. How will payment limits for DCAPS drugs be determined in 2025 Medicare Fee Schedule Lookup?
Payment limits for DCAPS drugs will be calculated using the Average Sales Price (ASP) methodology once that data becomes available. If ASP data isn’t available, CMS is proposing alternative payment mechanisms to establish limits for these drugs.
54. What about the administration fees for DCAPS drugs?
The proposed payment limits for the supply and administration of DCAPS drugs will be similar to the fees established under the ASP methodology. This ensures that the reimbursement structure for these additional preventive services remains consistent and fair in the upcoming Medicare Fee Schedule Lookup.
55. Will the payment structure for DCAPS drugs differ in RHCs and FQHCs?
Yes, in RHCs and FQHCs, both the DCAPS drugs and the administration fees will be paid at 100% of the Medicare payment amount. This payment will be processed on a claim-by-claim basis, streamlining the reimbursement process for these facilities.
56. What is the EPCS compliance deadline for long-term care (LTC) facilities in the Medicare Fee Schedule Lookup?
The deadline for including prescriptions from LTC facilities in the CMS EPCS Program compliance is proposed to be extended to January 1, 2028. Non-compliance actions would start after that date.
57. When is the next data reporting period for clinical diagnostic laboratory tests (CDLTs)?
The next data reporting period for CDLTs that are not advanced diagnostic laboratory tests (ADLTs) is from January 1, 2025, to March 31, 2025. The data will be based on information collected between January 1, 2019, and June 30, 2019.
58. What is the proposed change for blood transfusions under the Ambulance Fee Schedule?
CMS is proposing to add low titer O+ whole blood transfusion (WBT) to the advanced life support level two (ALS2) procedures for Medicare Fee Schedule Lookup 2025. If WBT is provided during a ground ambulance transport, the transport would be classified as ALS2.
Conclusion
By addressing these key questions, providers can better navigate the CY 2025 Medicare Physician Fee Schedule. It’s important to stay up to date with the changes by regularly consulting the Medicare fee schedule lookup and understanding the latest Medicare payment rules. This will ensure accurate billing and compliance with the 2025 Medicare physician fee schedule and protect your revenue.
