On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule (PFS) final rule. Of note, the 2025 PFS conversion factor is $32.3465, reduced by 2.83% from $33.2875 in 2024. Overall reimbursement for rheumatologic services is projected to remain flat compared to 2024, with changes to policies and individual services roughly balancing out.
Current practices, including conversion factor cuts for budget neutrality and a 0% payment update that fails to account for significant inflation in practice costs, create long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating rheumatologists and services.
In response to advocacy efforts of the ACR and other medical societies, Rep. Greg Murphy, MD (R-N.C.), recently introduced the Medicare Patient Access and Practice Stabilization Act of 2024, which would eliminate the 2.83% payment cut and provide an inflationary update for 2025 equal to 50% of the Medicare Economic Index. The legislation currently has 25 co-sponsors. ACR members are encouraged to urge their lawmakers to cosponsor this critically important bill.
In addition to the payment cuts, the CMS finalized significant policies related to telemedicine, Part B and Part D prescription drugs, chemotherapy administration codes, changes to the Merit-Based Incentive Payment System (MIPS) and several other important policies.
Telemedicine
The CMS maintains that it has limited statutory authority to extend most Medicare telemedicine policies. Without congressional action, the major Medicare telemedicine waivers will expire on Dec. 31, 2024, and return to policies that were in effect prior to the COVID-19 public health emergency.
Several bills under consideration in Congress would extend or make these flexibilities permanent. The ACR continues to encourage the CMS to work with Congress to permanently extend all regulatory flexibilities on telemedicine reimbursement.
We also continue to call 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.
Non-chemotherapy Administration
In response to concerns from the ACR and other stakeholders, the CMS is finalizing clarification to the Medicare Administrative Contractors regarding the administration of infusion for certain 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.
However, the ACR will continue to encourage the CMS to remove the “chemotherapy” terminology from the claims processing manual and replace it with “immunomodulatory therapies.” The ACR will also remain steadfast with our recommendation from previous years that the CMS work with key stakeholders and convene the necessary workgroups to create 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.
Changes to Relevant Procedure Codes
The CMS is finalizing changes to procedure codes relevant to rheumatologists, with the following cuts from calendar year 2024 (CY24) (most significant cuts in bold):
- 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa): $2.49 cut;
- 96365 (Intravenous infusion (IV) for therapy, prophylaxis, or diagnostic, initial): $3.64 cut;
- 96374 (Therapeutic prophylactic, or diagnostic injection, intravenous push single or initial): $2.04 cut;
- 96401 (Chemotherapy administration, subcutaneous or intramuscular): $4.50 cut; and
- 96413 (Chemotherapy administration, initial up to 1 hr): $7.68 cut.
Part B and Part D Drugs
The CMS is finalizing 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. This 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 applauds this change, noting it could be particularly important in situations where average sales price data are 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.
G2211
The CMS finalized its proposal to expand the add-on code for complexity, G2211, by allowing it to be billed when the underlying evaluation and management (E/M) service is performed on the same day as an annual wellness visit, vaccine administration or any Medicare Part B preventive service furnished in the office or outpatient setting.
Although the ACR supports this incremental change, we will continue to iterate our desire for the restrictions on modifier -25 to be removed completely.
MIPS
The final rule includes some changes to MIPS for CY 2025. Key points include:
- Maintaining 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.
- No change to performance category weights for Quality, Promoting Interoperability, Improvement Activities and Cost this performance year. The categories will be weighted as:
- Quality: 30%
- Cost: 30%
- Promoting Interoperability: 25%
- Improvement Activities: 15%
- Maintaining the data completeness threshold for the MIPS Quality Performance Category at 75% for the 2025 through 2028 performance years, a change from previous proposed rules that stated the data completeness threshold would increase to 80% in 2027.
- Adding six new measures in the Cost category, including Rheumatoid Arthritis. In response to calls from ACR, the CMS is adding biosimilars to the measure.
- Adding Adult Covid-19 Vaccination Status to the Rheumatology measure set and finalizing denominator changes for ACR-stewarded rheumatology measures QPP177, QPP178 and QPP180.
- Finalizing the removal of four improvement activities, including IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record, and delaying the removal of IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop.
The CMS continues to encourage eligible clinicians to move to MIPS Value Pathway (MVP) reporting. It did not provide a timeline for sunsetting of traditional MIPS. The Advancing Rheumatology Patient Care MVP now includes the Rheumatoid Arthritis cost measure, three additional quality measures and one additional improvement activity.
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.
