Understanding the Compliance Risks with New Payment Rules

The Centers for Medicare & Medicaid Services (CMS) has published several new proposed rules regarding Medicare payments for 2025. In addition to updating payment rates, there are a large number of coding, coverage, and quality measure changes for different provider types.

For physicians, CMS is proposing an overall 2.93-percent average payment rate decrease in the fee schedule, mainly due to changes required under law. This will stand unless Congress changes it.

CMS is proposing to establish new coding and payment guidelines for caregiver training for direct care services and supports, including but not limited to techniques to prevent decubitus ulcer formation, wound dressing changes, infection control, special diet preparation, and medication administration. Another set of codes and payment guidelines are proposed for caregiver behavior management and modification training, which could be furnished to the caregiver(s) of an individual patient. These proposed services could be furnished via telehealth.

CMS is also proposing to allow payment of the Office/Outpatient (O/O) Evaluation and Management (E&M) visit complexity add-on code G2211 when the O/O E/M base code is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service furnished in the office or an outpatient setting.

Additionally, CMS is proposing to add several services to the Medicare Telehealth Services List on a provisional basis, including demonstration prior to initiation of home International Normalized Ratio (INR) monitoring and caregiver training services. They also propose to continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for 2025.

CMS is also proposing to establish coding and make payment guidelines for a new set of Advanced Primary Care Management services denoted by three new HCPCS G-codes.

Based on the results of a CMS Innovation Center Model Program, CMS is proposing coding and payment guidelines for an Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment service and risk management services. The risk assessment would be performed in conjunction with an E&M visit when a practitioner identifies a patient at risk for cardiovascular disease who does not have a such a diagnosis.

The agency also is proposing a new HCPCS add-on code to describe the intensity and complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease, performed by a physician with specialized training in infectious diseases.

Also among the new proposals is a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services.

And CMS indicated it would like to add to the list of clinical scenarios under which fee-for-service (FFS) Medicare payment may be made for dental services inextricably linked to covered services.

There are several other proposed payment and policy changes for some drug and immunization services, specifically for Federally Qualified Health Centers and for Rural Health Clinics.

In the Outpatient Hospital Prospective Payment and Ambulatory Surgical Center (ASC) Proposed Rule, payment rates for those provider types have been increased by 2.6 percent. 

Some proposed updates to coverage include temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) and ASC settings from Jan. 1, 2025 through Dec. 31, 2027; these include refinements to the existing packaging policy to improve the accuracy of the overall payment amounts by paying separately for any diagnostic radiopharmaceutical with a per-day cost greater than $630, and removing their costs from the payment amounts for the nuclear medicine tests.

For the Hospital Outpatient Quality Reporting (OQR) Program, CMS is proposing to adopt: a) the Hospital Commitment to Health Equity (HCHE) measure, beginning with the 2025 reporting period/2027 payment determination; b) the Screening for Social Drivers of Health (SDoH) measure, beginning with voluntary reporting in the 2025 reporting period, followed by mandatory reporting beginning with the 2026 reporting period/2028 payment determination; and c) the Screen Positive Rate for Social Drivers of Health (SDoH) measure, beginning with voluntary reporting in the 2025 reporting period, followed by mandatory reporting beginning in 2026.

And finally, CMS is proposing new Conditions of Participation (CoPs) for hospitals and Critical Access Hospitals (CAHs) for obstetrical services, including new requirements for maternal quality assessment and performance improvement (QAPI), baseline standards for the organization, staffing, and delivery of care within obstetrical units, and staff training on evidence-based maternal health practices, on an annual basis.