The Centers for Medicare and Medicaid Services (CMS) released the proposed 2025 Medicare Physician Fee Schedule (PFS) on July 10, addressing Medicare payment and quality provisions for physicians in the coming year. Under the proposal, physicians will see a decrease to the conversion factor of 2.80% on Jan. 1, 2025, dropping from $33.2875 to $32.3562.

CMS projects that overall reimbursement for cardiovascular services will remain flat compared to 2024, with changes to policies and individual services roughly balancing out. This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice.  

Budget neutrality-related cuts have significantly impacted physicians in recent years. In addition to the across-the-board 2.8% reduction proposed this year, previous fee schedules have seen a nearly 2% reduction in 2023 on top of cuts of 0.8% and 3.3% in 2022 and 2021, respectively. This trend, combined with potential reductions related to PAYGO and sequestration, and the failure to account for significant inflation in practice costs, creates long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating physicians and services.

The ACC, along with other medical societies, has aligned with the American Medical Association (AMA) on a set of principles to guide advocacy efforts on Medicare physician payment reform. The ACC strongly supports the Strengthening Medicare for Patients and Providers Act (H.R. 2474), which would provide a permanent, annual inflationary update equal to the increase in the Medicare Economic Index, allowing physicians to invest in their practices and implement new strategies to provide high-value care.

The ACC will also continue its ongoing work to explore and promote approaches to stabilize the health care system and foster a successful, widespread transition to value-based care that reflects the needs of cardiovascular patients and clinicians in every setting. Visit the ACC’s grassroots page for ways to advocate for the financial stability of physician practices and preserving Medicare beneficiaries’ access to care.

Highlights from the proposed rule regarding payment policy, rate setting and quality provisions include:

Physician Fee Schedule

• The proposed rule includes work and/or practice expense (PE) values for new/revised codes. No new codes were created nor existing codes revised for cardiovascular services for 2025. More information is available in supporting data tables.
• In continuing to seek out ways to incorporate refreshed data to the fee schedule – such as the ongoing AMA Physician Practice Information Survey – CMS has retained the RAND Corporation to develop other methods for measuring practice expenses and updating payments.
• 90-day Global Surgical Packages: CMS proposes to “broaden the applicability of transfer of care modifiers” for 90-day global services to more accurately deliver reimbursement by breaking down payments to preoperative management, surgical care only and postoperative management only. The agency is also creating a new code, GPOC1, for postoperative care services to more appropriately compensate this care when rendered by a practitioner that was not involved in the surgical procedure.
• G2211 Update: CMS proposes to allow payment on the evaluation and management (E/M) visit complexity add-on code when the base E/M code is reported on the same day by the same practitioner as an annual wellness visit, vaccine administration or any Medicare Part B preventative service is performed. This was previously prohibited as G2211 was not allowed to be paid on any claim that used the -25 modifier.  
• ASCVD Screening: CMS proposes to create coding and payment for Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment and risk management services. This assessment would be performed in conjunction with an E/M visit when a risk factor is identified without prior diagnosis. Risk management services would include the ABCS of cardiovascular disease risk reduction: aspirin, blood pressure management, cholesterol management, smoking cessation.
• Radiopharmaceuticals in Physician Office: CMS proposes to clarify what methodologies are available to Medicare Administrative Contractors (MACs) for pricing of radiopharmaceuticals in the physician office setting. MACs may use any methodology used to determine payment limits for radiopharmaceuticals in place on or prior to November 2003. This may include, but is not limited to, invoice pricing.

Telehealth Provisions

• CMS proposes to unwind geographic location telehealth flexibilities that began during the COVID-19 public health emergency and were extended through 2024 by Congress, as required by current law. Starting Jan. 1, 2025, telehealth originating site rules would limit patient location to certain rural and underserved areas. Several bills under consideration in Congress would extend or make telehealth flexibilities permanent.
• For 2025 and beyond, CMS proposes to allow two-way, real-time audio-only communication to satisfy the requirement for an interactive telecommunications system, when appropriate. 
• The agency also proposes to maintain cardiac rehabilitation services on the telehealth list provisionally through 2025.
• Telemedicine E/M New Codes: the CPT® Editorial Panel created 17 new codes to describe new and established E/M visits performed via audio-visual or audio-only means with values recommended from the Relative Value Scale Update Committee (RUC) for the 2025 rule. CMS did not assign values to these codes, stating that the existing E/M codes with appropriate modifiers should be used for these scenarios instead. One code, 9X091 (virtual check-in), was valued at the RUC-recommended 0.30 work relative value unit and will replace code G2012 (brief communication technology-based service, e.g. virtual check-in).  
• CMS proposes to continue to allow teaching physicians to use audio/video real-time communications technology when the resident furnishes Medicare telehealth services in all teaching settings and only in clinical settings when the service is furnished virtually (for example, a three-way telehealth visit with the patient, resident and teaching physician all in separate locations) through Dec. 31, 2025.

2025 QPP Performance Period

CMS is proposing several updates to the Quality Payment Program (QPP) and Medicare Shared Savings Program (MSSP) for 2025.

• CMS is requesting information on sunsetting the traditional Merit-based Incentive Payment System (MIPS) and completing the transition to MIPS Value Pathways for the 2027 reporting year/2029 performance period.
• There is also an information request on a potential ambulatory specialty care model that incorporates MVPs to increase specialist engagement in value-based care and expand incentives for primary and specialty care coordination.
• A new MVP targeting surgical care, which would encompass procedures provided by cardiothoracic surgeons, has been proposed by the agency.
• CMS proposes modifying the previously finalized Advancing Care for Heart Disease MVP within the quality performance category to add one quality measure and improvement activity.
• The proposed rule includes the addition of six new proposed MVPs to be available for the 2025 performance year, along with limited modifications to previously finalized MVPs.
• The rule proposes requiring MSSP Accountable Care Organizations (ACOs) to report the new Advanced Practice Provider Plus quality measure set and to submit their measures through the electronic care quality measure (CQM) or Medicare CQM collection types.
• In addition, CMS proposes modifying the Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure to clarify that it does not apply to individual clinicians.
• Changes to the newly titled Inpatient PCI Cost Measure including the patient cohort, additional stratification and risk-adjustment, are included in the proposed rule.
• The proposed rule would maintain the performance threshold at 75 points for the 2025 performance year.
• Minor changes to the Cost, Quality, Improvement Activities and Promoting Interoperability performance categories have been proposed. For the 2025 performance period/2027 MIPS payment year, the scoring weights are as follows: 30% for the quality performance category; 30% for the cost performance category; 15% for the improvement activities performance category; and 25% for the promoting interoperability performance category.
• CMS proposes a total of 196 quality measures for the 2025 performance period by addressing changes to 66 existing MIPS quality measures, removing 11 quality measures, and adding nine quality measures, including two patient-reported outcomes measures.
• The rule includes a proposal where ACOs with a history of earned shared savings can apply to CMS for Pre-paid Shared Savings, at least 50% of which must be spent on direct patient services not otherwise payable in traditional Medicare (such as meals, dental, vision hearing and Medicare Part B cost sharing reductions) and up to 50% can be spent on staffing and infrastructure.
• CMS proposes the addition of a Health Equity Benchmark Adjustment (HEBA) to adjust ACOs’ historical benchmark on the proportion of assigned patients enrolled in Medicare Part D low-income subsidy or dually eligible for Medicare and Medicaid to increase ACO participation in rural and other underserved areas.
• The rule also proposes providing ongoing protection to ACOs from significant, anomalous and highly suspect billing activity such as that recently seen with multi-billion-dollar catheter billing fraud.
• CMS is soliciting comments on whether the current level of risk and reward available to ACOs participating in the ENHANCED track (the highest level of risk/reward currently available to ACOs) should be modified to create an even greater risk/reward option.
• CMS proposes establishing a methodology to account for improper payments in recalculating expenditures and payment amounts in the MSSP.

Additional information on the proposed rule can be found in the Medicare PFS Press Release, Medicare PFS Fact Sheet, MSSP Fact Sheet and QPP Fact Sheet. ACC Advocacy staff will continue to provide more detailed information on elements of the proposed rule in the weeks ahead and develop comments for submission within the 60-day comment period. Look for updated information on ACC.org/Advocacy and in upcoming issues of The Advocate newsletter.

Keywords: ACC Advocacy, Fee Schedules, Centers for Medicare and Medicaid Services, U.S., Physicians, Telemedicine, Policy

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