In early November, CMS finalized the 2025 Physician Fee Schedule Final Rule, the guiding document that determines payment policies for traditional Medicare. It also has important implications for Medicare Advantage and state Medicaid programs as well. You’ve likely heard about the clear displeasure in the physician community for the reduction in the conversion factor in the final rule, though CMS was hard-pressed to do otherwise given the existing budget neutrality requirement. There is concerted effort among professional associations to encourage Congressional action to mitigate the extent of the cuts and they may well make progress.
The 2025 rule includes changes for advanced primary care and telehealth, subjects dear to our readers’ hearts. Here is a recap of the introduction of Advanced Primary Care Management (APCM) codes and changes to telehealth policy in the final rule.
Advanced Primary Care Management
On the positive side, CMS finalized a set of three new G-codes for advanced primary care management (APCM) services (G0556, G0557, and G0558) that allow a monthly payment for advanced primary care management at one of three levels, depending on the number of chronic conditions a beneficiary has and whether the beneficiary is enrolled as a qualified Medicare beneficiary. Unlike the Chronic Care Management (CCM) and similar codes, the APCM codes are not time-based and cover a range of services from care management to communication-technology-based services. The range of services associated with the codes will be very familiar given how well-rooted care management and advanced primary care are in Michigan. The existing piecemeal codes (CCM, TCM, etc.) would be redundant to the services intended to be delivered under the APCM codes and could not be billed alongside them.
Table 27 of the final rule below shows the three new codes that could be billed on a monthly basis by the Qualified Health Professional (QHP) who is the continuing focal point for needed health care services and care coordination for a Traditional Medicare beneficiary. Here are the code descriptors and payment rates for the three levels of APCM codes:
We covered the basics of the Advanced Primary Care Management (APCM) codes in the proposed rule in our September/October edition. As in the proposed rule, an initiating visit is necessary for new patients and patient consent is required but can be accomplished in a variety of ways for new and existing patients.
CMS largely stayed true to their proposed APCM approach, though the Final Rule includes a few changes from the proposed rule. These changes were made based upon public comments. The changes were: 1) increasing the G0556 monthly payment from $10 to $15 per month, 2) permitting Annual Wellness Visits to serve as initiating visits, 3) widening the 24/7 requirement to allow for an after-hours responder that would document and communicate their interaction with the patient to the primary care team/practitioner, with that interaction documented in the patient’s medical record, and 4) clarifying that interprofessional consultation codes (CPT codes 99446-99449 and 99451) can be billed concurrently with APCM services.
CMS could not exempt the new codes from the Traditional Medicare 20% patient cost share, as it is not within their authority. However, since 90% of Traditional Medicare patients have supplementary policies, the vast majority of these patients would not face a financial barrier.
CMS’ introduction of advanced primary management codes is to be applauded. It is a positive and important step to increase resources for care management in a way that decreases administrative burden on practices.
Telehealth
CMS does not have the authority to extend the bulk of Medicare telehealth waivers that were put in place during the pandemic that provided an array of reimbursable codes for servicing patients via telehealth. Thus, many of these flexibilities will expire at the end of this year. Extending or making these waiver provisions permanent would require Congressional action such as the Telehealth Modernization Act of 2024.
Given this, in the CMS Final Rule, pre-pandemic geographic and location restrictions for telehealth are being reinstated. This means that for the most part, unless a Medicare patient lives or is located in a health professional shortage area, a rural census track, or a county outside of the metropolitan statistical area at the time of service they will not be covered for telehealth services.
As well, starting in 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.
We are staying tuned to the progress of bills introduced in Congress to extend telehealth flexibilities but are mindful that the clock is ticking as it is already November.
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