Summary of Notable Provisions in CY 2025 Medicare PFS Proposed Rule

On July 10, 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). The proposed rule has a 60-day comment period. 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 will provide comments on the following provisions.

Fee Schedule Provisions

Physician Reimbursement

• The 2025 proposed conversion factor (CF) is $32.3562. This represents a 2.8% decrease from the 2024 CF 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 & Children’s Health Insurance Program Reauthorization Act; and a .05% budget-neutrality adjustment.
• The overall reimbursement for rheumatological services is projected to remain flat compared with 2024.

Non-chemotherapy Administration

• The CMS is proposing clarification to Medicare Administrative Contractors (MACs) regarding the administration of infusion 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.

Part B and 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 by more than the rate of inflation.
• The CMS is proposing a host of methodological changes related to the calculation of rebates for impacted drugs.

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 CMS is proposing to permanently reimburse for two-way, real-time audio-only communication to satisfy the requirement for an interactive telecommunications system, when appropriate. 

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.

Quality Payment Program

• The CMS is proposing to maintain the performance threshold at 75 points for CY 2025. Scoring 75 or more points would allow an individual or group a payment bonus; scoring fewer than 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 weighting at 25% and 15%, respectively.
• The CMS will maintain the data completeness threshold for the MIPS quality performance category at 75% for the 2025–2028 performance years. This marks a change from previous proposed rules that 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 set.
• The CMS is proposing various changes to the Advancing Rheumatology Patient Care MVP.

ACR/ARP members should email the ACR’s advocacy team at [email protected] with any questions and comments. We will monitor the rule’s implementation and serve as an educational resource for members on its provisions and the impact they will have on rheumatology.