The Centers for Medicare and Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule (PFS) final rule on Nov. 1. Of note, the 2025 PFS conversion factor is $32.3465, reduced 2.83% from $33.2875 in 2024. Overall reimbursement for cardiovascular services is projected to remain flat compared to 2024, with changes to policies and individual services roughly balancing out. However, individuals and groups will see different impacts depending on patient populations and services offered.

Both conversion factor cuts for budget neutrality and a 0% payment update that fails 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. 

In response to advocacy efforts from the ACC and other medical societies, Congress 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. "We appreciate the support from congressional leaders backing this legislation and look forward to working with the broader medical community and Congress to pass this much-needed bipartisan legislation," said ACC President Cathleen Biga, MSN, FACC. ACC members are encouraged to urge their lawmakers to cosponsor the bill. 

Looking ahead at long-term reform, the ACC strongly supports the Strengthening Medicare for Patients and Providers Act (H.R. 2474), which aims to provide a permanent, annual update equal to the increase in the Medicare Economic Index. The College also supports efforts to increase the budget neutrality threshold from $20 million to $53 million to mitigate year-to-year cuts, a policy featured in both the Provider Reimbursement Stability Act (H.R. 6371) and the Physician Fee Stabilization Act (S. 4935).

The ACC continues to explore policy solutions that promote health care system stability and foster a successful, widespread transition to value-based care, reflecting the needs of cardiovascular patients and clinicians in every setting.

In addition to PFS conversion factor updates, the final rule addresses telehealth policies, cardiac computed tomography (CT) services, global payment policy, new atherosclerotic cardiovascular disease (ASCVD) risk assessment and management codes, new and revised CPT® code valuations, and the Merit-based Incentive Payment System (MIPS) to MIPS Value Pathway (MVP) transition.

Notable cardiovascular-related components of the final rule include: 

G2211 Update: CMS will allow payment for 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.   

Radiopharmaceuticals in Physician Office: CMS clarified that Medicare Administrative Contractors may use any methodology used to determine payment limits for radiopharmaceuticals in place on or prior to November 2003, including invoice pricing.

Telemedicine Flexibilities: 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.  
• 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.  
• Cardiac rehabilitation and other services that require direct supervision will be able to meet that requirement through the immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through 2025. The agency will also maintain cardiac rehabilitation services on the telehealth list provisionally through 2025.

ASCVD Risk Assessment and Management G Codes: CMS finalized a proposal to create coding and payment for ASCVD risk assessment and risk management services.  

• The risk assessment code, G0537, would cover the administration of an ASCVD risk assessment tool such as ACC’s ASCVD Risk Estimator or the American Heart Association’s PREVENT Tool. The assessment should be done on a patient that does not currently have a cardiovascular disease diagnosis or history of heart attack or stroke and has at least one predisposing condition that would put them at risk for future ASCVD diagnosis. Examples of such conditions include obesity, family history of cardiovascular disease, history of high blood pressure, history of high cholesterol, history of smoking/alcohol/drug use, pre-diabetes or diabetes.   
• The risk management services code, G0538, would be reimbursable on patients found to have intermediate, medium or high risk for cardiovascular disease as determined by the ASCVD risk assessment and would include medication management, blood pressure management, cholesterol management and smoking cessation.   
• Both codes have a work RVU of 0.18.

Global Payment Policy Accuracy Efforts: CMS has finalized several rules aimed at ensuring accurate and appropriate payment of global surgical codes.  

• Beginning in 2025, the -54 modifier (Surgical Care Only: this modifier is appended to the relevant global package code to indicate that the proceduralist performed only the surgical procedure portion of the global package) is required for all 90-day global surgical packages in any case when a practitioner plans to furnish only the surgical procedure portion of the global package. 
• Under the rule, this modifier does not require a formal transfer of care agreement between the practitioner performing the surgical procedure and the practitioner that would perform the follow-up visits and care.   
• Payment for the surgical procedure will be adjusted to account for the removal of the non-surgical portion of the code’s reimbursement.  
• A postoperative add-on code, G0559, has been created to address the resources used when postoperative care is provided during the 90-day global period by a practitioner that did not perform the procedure and is of a different specialty and practice.  
• This add-on code does not require a formal transfer of care agreement to be billed during the 90-day global period. 
• The G0559 add-on code will have a work RVU of 0.16.

New/Revised CPT Code Valuations: There were no new or revised CPT codes directly related to cardiovascular care in this rule.   

• The CPT Editorial Panel created 17 new telehealth E/M codes to describe new and established E/M visits performed via audio-visual or audio-only means with values recommended from the RUC.  
• CMS cited statute that would require services regularly performed in-person must be reimbursed at the same rate as those services being furnished via telehealth.  
• CMS finalized the RUC-recommended values for 16 of the codes but assigned them a payment status indicator noting that there are more specific codes that should be used for these services. The agency advises that the appropriate coding and billing for these codes would be the existing E/M codes with appropriate modifiers for telehealth instead of this newly created code set.  
• One code, 98016 (virtual check-in), was valued at the RUC-recommended 0.30 work RVU and will replace code G2012 (brief communication technology-based service, e.g. virtual check-in). CMS notes that this code was allowed and activated within the Medicare PFS since it is not a service regularly performed in person and therefore does not conflict with statute.

Quality Payment Program (QPP):

• There are minimal changes to the MIPS program for the 2025 performance year, including the addition of seven new quality measures and the removal of 10 quality measures. 
• CMS added one new quality measure and one new improvement activity to the Advancing Care for Heart Disease MVP.  
• In its response to a request for information on transitioning MIPS reporting to mandatory MVPs, the ACC expressed concerns about the lack of applicability to large multispecialty groups and Accountable Care Organization (ACO)-affiliated clinicians. CMS did not propose any action in this rule, and the College will monitor proposals in future rulemaking.

Medicare Shared Savings Program (MSSP):

• The rule finalized an optional prepaid shared savings program for eligible ACOs with a history of earning shared savings. The ACO would need to apply and be determined eligible to receive prepaid shared savings – an advance to be used for investments to aid beneficiaries.    
• CMS established a Health Equity Benchmark Adjustment (HEBA) to provide financial incentives to ACOs that serve underserved communities and encourage ACOs serving higher proportions of beneficiaries in these communities to enter and remain in the MSSP.  
• The rule also includes protections for MSSP ACOs and their aligned clinicians from potential financial damages from “significant, anomalous, and highly suspect billing activity.” 
• The agency adopted the Advanced Practice Provider Plus quality measure set with a three-year phase-in process.

The full text of the final rule can be found here. Additional information can be found in the accompanying CMS press release, Medicare PFS fact sheet, MSSP fact sheet and QPP fact sheets.

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