On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule (PFS) final rule. Of note, the 2025 PFS conversion factor is $32.3465, reduced by 2.83% from $33.2875 in 2024. Overall reimbursement for rheumatologic services is projected to remain flat compared to 2024, with changes to policies and individual services roughly balancing out.
Current practices, including conversion factor cuts for budget neutrality and a 0% payment update that fails to account for significant inflation in practice costs, create long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating rheumatologists and services.
In response to advocacy efforts of the ACR and other medical societies, Rep. Greg Murphy, MD (R-N.C.), 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. The legislation currently has 25 co-sponsors. ACR members are encouraged to urge their lawmakers to cosponsor this critically important bill.
In addition to the payment cuts, the CMS finalized significant policies related to telemedicine, Part B and Part D prescription drugs, chemotherapy administration codes, changes to the Merit-Based Incentive Payment System (MIPS) and several other important policies.
Telemedicine
The CMS maintains that it has limited statutory authority to extend most Medicare telemedicine policies. Without congressional action, the major Medicare telemedicine waivers will expire on Dec. 31, 2024, and return to policies that were in effect prior to the COVID-19 public health emergency.
Several bills under consideration in Congress would extend or make these flexibilities permanent. The ACR continues to encourage the CMS to work with Congress to permanently extend all regulatory flexibilities on telemedicine reimbursement.
We also continue to call for the CMS to remove all restrictions on payment parity and remove any barriers to interstate licensure that bar providers from treating beneficiaries across state lines.
Non-chemotherapy Administration
In response to concerns from the ACR and other stakeholders, the CMS is finalizing clarification to the Medicare Administrative Contractors regarding the administration of infusion for certain 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.
However, the ACR will continue to encourage the CMS to remove the “chemotherapy” terminology from the claims processing manual and replace it with “immunomodulatory therapies.” The ACR will also remain steadfast with our recommendation from previous years that the CMS work with key stakeholders and convene the necessary workgroups to create 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.
