November 1, 2024, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2025 Physician Fee Schedule (PFS) Final Rule, introducing numerous changes to the Medicare program’s payment and coding policies. Understanding these changes is crucial for practices to successfully navigate CMS’s 2025 updates to healthcare regulations and coding.
Veradigm recently invited renowned billing and coding expert Nancy M. Enos from Enos Medical Coding to present a webinar, 2025 CMS Update.1 Here are highlights from the webinar to help practices understand 2025 changes.
One of the key changes is that the CY 2025 PFS Final Rule brings another conversion factor reduction, which will significantly impact physician reimbursement for 2025. CMS finalized the 2025 PFS conversion factor as $32.35, representing a decrease of $0.94 (2.83%) from 2024 physician and clinician payment amounts. The change will reduce final average payment rates under the PFS by 2.93% compared to average payment rates for most of CY 2024.2
Several rules allowing greater telehealth flexibility were implemented during the COVID-19 public health emergency. However, without Congressional intervention, many of these flexibilities were scheduled to end January 1, 2025. Congress recently passed the American Relief Act of 2025, which extends many of these telehealth flexibilities through March 31, 2025, including:
In the Final Rule, CMS continues the suspension of limitations on telehealth frequency, allowing subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations as frequently as medically necessary. CMS also extended telehealth flexibilities allowing audio-only telehealth visits; extended flexibility for physicians to provide direct supervision in low-risk settings via real-time audio and visual interactive communication; and added provisions allowing teaching physicians to continue to have a virtual presence for telehealth services involving residents.3
CMS is also changing policies and expanding some payment options under the APCM system, including the introduction of several new Healthcare Common Procedure Coding System (HCPCS) G-codes . The finalized APCM services bundles elements of several previous care management and communication technology-based services.
Unlike previous care management codes, the new codes have no time-based thresholds. This is intended to reduce the administrative burden of coding and billing for these services. Instead, CMS introduces 3 new HCPCS G-codes to stratify APCM into 3 levels based on individual patients’ number of chronic conditions and status as a Qualified Medicare Beneficiary.4
Another focus area for CMS updates is addressing patients’ social needs to enhance their healthcare outcomes. The Final Rule included CMS updates to 3 recently implemented initiatives that target patients’ social needs.
CHI services focus on addressing broader health needs within communities via strategies such as coordinating with community resources to assist patients. CHI works to provide support for social and environmental health factors and, at the same time, helps to integrate patients’ care with public health initiatives. For example, CHI might help connect patients with housing, food, or transportation assistance.
The Final Rule introduces new CPT codes for CHI services, including codes for patients’ Initial Assessment and Follow-up Visits.
Similarly, the Final Rule introduces new CPT codes for identifying and addressing social factors that may impact patient health, such as housing insecurity, food insecurity, or lack of access to appropriate healthcare. SDoH Risk Assessment provides data enabling providers to tailor care plans to address patients’ unique challenges, improving outcomes through holistic patient care.
CPT codes for SDoH Risk Assessment cover patients’ Initial Assessment and Follow-up Visits.
PIN services focus on helping improve care for patients with serious or complex health conditions. PIN provides patients with dedicated healthcare navigators who help streamline communication between patients, providers, and caregivers. Trained Principal Illness Navigators often assist cancer patients and patients with complex chronic conditions, such as heart or lung disease; they also help patients who need assistance with post-hospital discharge planning to reduce their risk for readmission.
CMS will pay for 3 time-based HCPCS codes in this category, covering Initial Visits, Follow-up Visits, and non-face-to-face visits, such as phone or email care management communication.
In the 2025 PFS Final Rule, CMS adds multiple new G-codes, expanding coverage in several areas. Initially introduced by CMS as part of the HCPCS, G-codes are used only for Medicare and Medicaid billing, where their role is to help describe medical procedures and services not currently covered by CPT codes. To ensure compliance with current CMS billing requirements, practices must regularly review G-code updates, including the services/procedures covered and documentation requirements.
Testing by the CMS Innovation Center Million Hearts® Model found that coupling payments for cardiovascular risk assessment with payments for cardiovascular care management reduced the numbers of patient heart attacks and strokes, reducing the overall patient death rate. In light of these results, CMS introduced new G-codes covering ASCVD risk assessment and management.7
Risk assessment is covered in conjunction with evaluation and management (E/M) patient visits when the provider identifies that a patient without a current cardiovascular disease diagnosis is at risk for cardiovascular disease. Risk assessment must include documentation of a 10-year estimate of the patient’s ASCVD risk. Risk management services are covered for beneficiaries who are at intermediate, medium, or high risk for cardiovascular disease during that 10-year period.8
CMS introduced G-codes to enable separate coding and payment for safety planning interventions for patients in crisis, including patients at risk of suicide or overdose. G-code payment may be billed in 20-minute increments when the billing practitioner personally performs safety planning, which may take place in a variety of settings. CMS also finalized payment for specific post-discharge follow-up patient contacts that occur in conjunction with the patient’s discharge from the emergency department for a crisis encounter.
In another effort to support patient access to behavioral health services, CMS finalized 6 new G-codes for diagnosing and treating mental illness. These G-codes allow billing by specialty practitioners whose covered services are limited to services for the diagnosis and treatment of mental illness, including clinical psychologists, clinical social workers, family and marriage therapists, and other mental health counselors. CMS also finalized 3 new G-codes related to digital mental health treatment, for use only with FDA-cleared digital mental health treatment devices used to augment a patient’s behavioral therapy plan.9
CMS has finalized add-on G-codes to describe the complexities of certain types of health care. Specifically, a new add-on G-code now exists to describe the intensity and complexity of hospital inpatient or observation care associated with suspected or confirmed cases of infectious disease when performed by a clinician with specialized training in infectious diseases.
CMS has also changed the use of an existing add-on G-code for office visits and outpatient E/M visit complexity. For 2025, this complexity add-on code can be reported by a clinician on the same day as a patient’s annual wellness visit or other Medicare Part B preventive service delivered in an outpatient setting.10
The 2025 Final Rule adds new coding and payment policies, with 5 new G-codes, for providing caregiver training related to patient direct care services and support; caregiver behavior management; and caregiver behavior modification.
The updated caregiver training policies allow caregiver training to be provided via telehealth.
Staying current with changes to the CMS billing and coding policies is essential for practices to remain compliant. One of the most efficient and effective way to do so? By integrating practice management software and revenue cycle management best practices that automatically keep you on top of these complex and ever-changing regulations. At Veradigm, we offer software and services that can help your practice navigate the increasingly complex revenue cycle landscape.
Veradigm’s Practice Management software is an end-to-end practice management solution. This solution includes an array of intuitive healthcare technologies to enable your practice to stay on top of your revenue cycle while maximizing operational efficiencies.
Veradigm Revenue Cycle Services (RCS) is an administrative and financial management solution that handles a practice’s revenue cycle from first contact to payment collection. This EHR-agnostic healthcare revenue cycle management service currently serves more than 29,000 providers and handles $4.2 billion in annual payments. Veradigm RCS can help your practice stay current with CMS billing and coding changes as well as regulatory changes created by MACRA, Meaningful Use, and others.
Veradigm Practice Management and Veradigm RCS can optimize your practice’s day-to-day operations and financial performance, letting your providers focus on patients. Contact us today to learn how Veradigm can help your practice overcome billing and revenue cycle challenges.
You can also contact us to view the full “2025 CMS Update” webinar and take an even more detailed look at changes covered in the CY 2025 PFS Final Rule.
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