The Centers for Medicare and Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule (PFS) final rule and the 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rule on Nov. 1. Of note, the 2025 PFS conversion factor is $32.3465, a reduction of 2.83% from $33.2875 in 2024. Overall, PFS reimbursement for cardiovascular services is projected to remain flat compared with 2024, with changes to policies and individual services roughly balancing out. Individuals and groups will see different impacts depending on patient populations and services offered.  

Initial highlights from the Medicare PFS final rule include: 

• Telemedicine Flexibility Extensions: Originating site location telehealth flexibilities that began during the COVID-19 public health emergency and were extended through 2024 by Congress will end, as required by current law. Starting Jan. 1, 2025, telehealth originating site rules will limit patient location to certain rural and underserved areas. Several bills under consideration in Congress would extend or make telehealth flexibilities permanent. 
• Starting Jan. 1, 2025, two-way, real-time audio-only communication will satisfy the requirement for an interactive telecommunications system under specific circumstances when a patient cannot use or does not consent to using video technology. However, the distant site practitioner must still have audio-video capabilities.  
• ASCVD Risk Assessment and Management G Codes: CMS finalized a proposal to create coding and payment for Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment and risk management services. Risk management services would include the following: aspirin (or other medications), blood pressure management, cholesterol management, smoking cessation.  
• Updated Code Values For New/Revised Services: The rule includes work and/or practice expense values for new/revised codes. No new codes were created nor existing codes revised expressly for cardiovascular services for 2025. More information is available in supporting data tables. 
• Telehealth Home Address Enrollment: Through calendar year 2025, CMS will continue to permit a distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. They will consider this issue further for future rulemaking.  
• Quality Payment Program: CMS added six new MIPS Value Pathways (MVPs) to be available for the 2025 performance year, along with revisions to all previously finalized MVPs.  

The 2025 Hospital OPPS final rule sets a 2.9% increase to OPPS payment rates to hospitals and ASCs that meet relevant quality reporting requirements, reflecting a market basket update of 3.4% reduced by a productivity adjustment of 0.5%. No changes were made to cardiovascular services on the Inpatient-Only List and the ASC Covered Procedures List (CPL).  

Notably, cardiac ablations were not added to the ASC CPL. The agency’s rationale was that the codes recommended for inclusion had “associated inpatient admissions, where the beneficiary requires active medical monitoring and care at midnight following the procedures.”  

CMS also finalized a proposal to separately pay for any diagnostic radiopharmaceutical with a per-day cost greater than $630, a policy the ACC supported to recognize enhanced costs in some areas while mitigating disruption in the prospective payment system.  

Additionally, CMS is temporarily reassigning some cardiac computed tomography (CT) codes from Ambulatory Payment Classification (APC) 5571, which pays about $178, to APC 5572, which pays about $357, in response to longstanding concerns and comments from the ACC and others. This move will more appropriately cover the costs of performing cardiac CT while CMS assesses claims data for potential revisions in future years.  

ACC Advocacy staff will provide a more detailed breakdown of the final rules in the coming days. Additional information on the rule can be found in the Medicare PFS Press Release, Medicare PFS Fact Sheet, Medicare Shared Savings Program Fact Sheet, and the Quality Payment Program Fact Sheet. OPPS resources include an OPPS Press Release and OPPS Fact Sheet. Look for updated information on ACC.org/Advocacy and in upcoming issues of The Advocate newsletter. 

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