In July, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule, which includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). Final regulations will be issued on or around Nov. 1 and, unless otherwise noted, policies will be effective on Jan. 1, 2025. Among others, the ACR provided comments on the following fee schedule provisions.
Physician Reimbursement
The 2025 proposed conversion factor is $32.3562. This represents a decrease of 2.8% from the 2024 conversion factor of $33.2875. The change to the PFS conversion factor reflects the expiration of the 2.93% statutory payment increase for CY 2024; a 0.00% conversion factor update under the Medicare Access and Children’s Health Insurance Program Reauthorization Act; and a 0.05% budget-neutrality adjustment.
With the grave impact that inflation has had on the cost of practicing medicine and the healthcare workforce shortage, this cut is draconian and counterintuitive to the purpose of Medicare. The ACR strongly urged the CMS not to proceed with this damaging adjustment, which will further harm already strained practices and exacerbate the ongoing workforce shortages.
Non-chemotherapy Administration
The CMS is proposing clarification to Medicare Administrative Contractors (MACs) regarding the administration of certain types of 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.
To reflect the diversity of specialties that infuse these drugs, the ACR requested that the CMS remove the “chemotherapy” terminology from the claims processing manual and replace it with “immunomodulatory therapies.” We also reiterated our recommendation from previous years that the CMS work with key stakeholders and convene the necessary workgroups in creating the 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.
Part B & Part D Drugs
The CMS is proposing to implement 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. The proposal 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.
