In July, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule, which includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). Final regulations will be issued on or around Nov. 1 and, unless otherwise noted, policies will be effective on Jan. 1, 2025. Among others, the ACR provided comments on the following fee schedule provisions.
Physician Reimbursement
The 2025 proposed conversion factor is $32.3562. This represents a decrease of 2.8% from the 2024 conversion factor of $33.2875. The change to the PFS conversion factor reflects the expiration of the 2.93% statutory payment increase for CY 2024; a 0.00% conversion factor update under the Medicare Access and Children’s Health Insurance Program Reauthorization Act; and a 0.05% budget-neutrality adjustment.
With the grave impact that inflation has had on the cost of practicing medicine and the healthcare workforce shortage, this cut is draconian and counterintuitive to the purpose of Medicare. The ACR strongly urged the CMS not to proceed with this damaging adjustment, which will further harm already strained practices and exacerbate the ongoing workforce shortages.
Non-chemotherapy Administration
The CMS is proposing clarification to Medicare Administrative Contractors (MACs) regarding the administration of certain types of drugs and biologics that can be considered complex and may be appropriately reported using chemotherapy administration CPT codes 96401-96549. This clarification will also provide complex clinical characteristics for the MACs to consider as criteria when determining payment of claims for these services.
To reflect the diversity of specialties that infuse these drugs, the ACR requested that the CMS remove the “chemotherapy” terminology from the claims processing manual and replace it with “immunomodulatory therapies.” We also reiterated our recommendation from previous years that the CMS work with key stakeholders and convene the necessary workgroups in creating the appropriate language and guidance in the claims processing manual so providers can bill the complex drug administration codes and avoid deleterious impacts on access and coverage for beneficiaries.
Part B & Part D Drugs
The CMS is proposing to implement requirements under the Inflation Reduction Act under which drug manufacturers must pay inflation rebates if they raise the price of certain Part B and Part D drugs higher than the rate of inflation. The proposal includes changes to the calculation for whether a Part B rebatable drug should have an adjusted beneficiary coinsurance equal to 20% of the inflation-adjusted payment amount.
The ACR expressed support for this proposal because it could be particularly important in situations where the average sales price (ASP) is very low or negative and other data are used to calculate the payment amount, resulting in an amount that exceeds the inflation-adjusted payment amount.
Telemedicine
The CMS is not proposing to extend the geographic-location telemedicine flexibilities that originated during the COVID-19 pandemic and were extended through 2024 by Congress. Starting Jan. 1, 2025, telemedicine originating-site specifications would limit patient location to certain rural and underserved areas. Several bills under consideration in Congress would extend or make telemedicine flexibilities permanent.
The ACR encouraged the CMS to work with Congress to permanently extend all regulatory flexibilities on telemedicine reimbursement. We also called for the CMS to remove all restrictions on payment parity and remove any barriers to interstate licensure that bar providers from treating beneficiaries across state lines.
The CMS is also proposing to permanently reimburse for two-way, real-time audio-only communication to satisfy the requirement for an interactive telecommunications system, when appropriate. The ACR expressed support for this proposal.
G2211
The CMS is proposing to pay for G2211 on claims that use modifier -25 to report a Medicare annual wellness visit, vaccine administration or Medicare Part B preventive service at the same encounter as an office/outpatient evaluation and management (E/M) service. Although the ACR expressed support for this incremental change, we iterated our desire for the restrictions on modifier -25 to be removed completely.
Quality Payment Program
The following are some of the changes the CMS is proposing to the Merit-Based Incentive Payment System (MIPS) for CY 2025:
- The CMS is proposing to maintain the performance threshold at 75 points for CY 2025. Scoring above 75 points would allow an individual or group a payment bonus; scoring below 75 points would result in a payment penalty in 2027.
- By law, the CMS is not proposing to change the category weights. The quality performance and cost performance categories will each be weighted at 30%. Promoting interoperability and improvement activities performance categories will maintain their respective 25% and 15% weights.
- The CMS will maintain the data completeness threshold for the MIPS quality performance category at 75% for the 2025 through 2028 performance years. This is a change from previous proposed rules, which stated the data completeness threshold would increase to 80% in 2027.
- The CMS is proposing to add six new measures in the cost category, including rheumatoid arthritis.
- The CMS is proposing to add adult Covid-19 vaccination status to the rheumatology measure set. It is also proposing changes to four existing measures in the rheumatology set.
- The CMS is proposing various changes to the Advancing Rheumatology Patient Care MIPS Value Pathway.
The ACR expressed support for these changes. However, the CMS is also proposing to sunset traditional MIPS in favor of MIPS Value Pathways (MVPs) for the 2029 reporting year/2031 performance period. The ACR has successfully encouraged rheumatologists to report the Advancing Rheumatology Patient Care MVP through the ACR’s Rheumatology Informatics System for Effectiveness (RISE) registry but has only experienced one reporting period. RISE users have also called for more specialty-specific measures in the MVP. Because measure development is a time- and resource-intensive activity, the ACR urged the CMS to allow more time for specialty-specific measures to be developed in MVPs before sunsetting traditional MIPS.
ACR/ARP members should email the ACR’s advocacy team at [email protected] with any questions and comments they may have. We will monitor the rule’s implementation and serve as an educational resource for members on its provisions and the impacts they will have on rheumatology.
