Physician Fee Schedule Final Rule for Calendar Year 2025

2025 conversion factor

$32.3465 (updated 11/19/2024)

Coverage of new HCPCS codes

On November 1, CMS released the final 2025 Medicare physician fee schedule. The rule contains dozens of new HCPCS codes that will take effect Jan. 1, 2025. From cardiovascular disease assessment and caregiver training services to a suite of behavioral health services, the new codes offer new ways to gain reimbursement and provide care to your patients. The round-up below provides a closer look at the new codes, their full descriptors, 2025 fees and key billing details.

Table of Contents

• Atherosclerotic Cardiovascular Disease (ASCVD) Risk Assessment, Management
• Caregiver Training Services, Behavior Management/Modification
• Caregiver Training Services, Direct Care Strategies
• Post-discharge Telephonic Follow-up Contacts Intervention
• Hospital Inpatient or Observation (I/O) Evaluation and Management (E/M) Add-on for Infectious Diseases
• Interprofessional Health Record Assessment and Management
• Digital Mental Health Treatment
• Advanced Primary Care Management Services
• Post-operative Care Services Add-on Code
• Safety Planning Interventions
• Physician Fee Schedule Final Rule Archives 2024 and previous (old news)

Atherosclerotic Cardiovascular Disease (ASCVD) Risk Assessment, Management

HCPCS codes: G0537, G0538

Descriptor:

• G0537 (Administration of a standardized, evidence-based Atherosclerotic Cardiovascular Disease [ASCVD] Risk Assessment for patients with ASCVD risk factors, 5-15 minutes, not more often than every 12 months per practitioner)
• G0538 (Atherosclerotic Cardiovascular Disease [ASCVD] risk management services; with the following required elements: patient is without a current diagnosis of ASCVD, but is determined to be at intermediate, medium, or high risk for CVD as previously determined by the ASCVD risk assessment; ASCVD-Specific care plan established, implemented, revised, or monitored that addresses risk factors and risk enhancers and must incorporate shared decision-making between the practitioner and the patient; clinical staff time directed by physician or other qualified health care professional; per calendar month)

2025 fees: G0537 ($18.44), G0538 ($15.20)

Key details: CMS finalized a new HCPCS code, G0537, for an atherosclerotic cardiovascular disease (ASCVD) risk assessment, which “is reasonable and necessary for a patient who has at least one predisposing condition to cardiovascular disease that may put them at increased risk for future ASCVD diagnosis,” CMS states in the final 2025 Medicare physician fee schedule. Applicable conditions include, but are not limited to, obesity, a family history of cardiovascular disease, a history of high blood pressure, a history of high cholesterol, pre-diabetes or diabetes, and a history of smoking or substance use.

In a reversal of the proposal, the risk assessment must not be provided on the same date as the E/M visit. “There are circumstances where test results may identify the need for an ASCVD risk assessment on a day other than the date of an E/M service, so [we] are not finalizing the requirement that the ASCVD risk assessment must be performed on the same date as the associated E/M visit,” the agency states.

The risk-assessment tool must be evidence-based, but CMS is not proposing a specific tool as a requirement. The agency offers evidence-based examples, which include the ACC ASCVD Risk Estimator and the AHA PREVENT tool.

The risk management portion of ASCVD is tied to proposed code G0538 and incorporates CVD risk reduction techniques for beneficiaries. The associated risk-management services involve the “development, implementation and monitoring of individualized care plans for reducing cardiovascular risk,” CMS says, with a focus on the “ACBS” model, which refers to “aspirin, blood pressure management, cholesterol management and smoking cessation.”

Note that in the final rule CMS tweaked the code descriptor to cover patients who are “at intermediate, medium, or high risk of CVD as previously identified through an ASCVD risk assessment.” The inclusion of “intermediate” broadens the risk levels to align with diverse risk-assessment tests.

Patient consent must be received (written or verbal), and documented in the medical record, prior to the service delivery, the agency says. There is no time requirement for the service, only that “each of the elements must be addressed to bill for the service, unless a particular element is not medically indicated or necessary at that time for that specific patient,” CMS says.

Caregiver Training Services, Behavior Management/Modification

HCPCS codes: G0539, G0540

Descriptor:

• G0539 (Caregiver training in behavior management/modification for caregiver[s] of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional [without the patient present], face-to-face; initial 30 minutes)
• G0540 ( … ; each additional 15 minutes)

2025 fees: G0539 ($52.08), G0540 ($25.55)

Key details: In ways similar to the 2023-effective behavior management/modification caregiver training codes 96202 and 96203 for group training, the newly proposed caregiver training services (CTS) codes G0539 and G0540 are instead oriented toward individual training, “furnished to the caregiver(s) of an individual patient,” according to CMS. “Behavior management/modification training for caregivers of Medicare beneficiaries should be directly relevant to the person-centered treatment plan for the patient in order for the services to be considered reasonable and necessary under the Medicare program,” CMS states. Patient consent is required and can be provided verbally by the patient.

Caregiver Training Services, Direct Care Strategies

HCPCS codes: G0541, G0542, G0543

Descriptor:

• G0541 (Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications [including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control] [without the patient present], face-to-face; initial 30 minutes)
• G0542 ( … ; each additional 15 minutes [List separately in addition to code for primary service])
• G0543 (Group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications [including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control] [without the patient present], face-to-face with multiple sets of caregivers).

2025 fees: G0541 ($52.08), G0542 ($25.55), G0543 ($22.00)

Key details: As opposed to the behavior management and functional performance improvement codes that CMS activated in 2024, a new series of HCPCS codes would focus on “direct care services and supports” and would apply to more hands-on care training, such as teaching how to change wound dressings or prevent decubitus ulcer formation. “Each training activity should be clearly identified and documented in the treatment plan,” CMS says.

The agency also clarified in the final rule that patients might be receiving care under other Medicare programs. “Caregiving raining may be appropriate for circumstances where a beneficiary’s caregiver need training, but the patient is under a home health plan of care, receiving at-home therapy, or receiving DME services for unrelated conditions,” the final rule states.

The three codes are designated as “sometimes therapy” services, which facilitates payment for the CTS services under the PFS for outpatient physical therapy, occupational therapy and speech-language pathology services “when personally furnished by PTs and OTs, including those provided by their supervised assistants … as well as the CTS personally furnished by SLPs.”

Post-discharge Telephonic Follow-up Contacts Intervention

HCPCS code: G0544

Descriptor: “Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, 4 calls per calendar month.”

2025 fee: $61.78

Key details: Seeking to address mental health issues, CMS finalized a telephonic follow-up contacts intervention (FCI) specifically for individuals with suicide risk or risk of deliberate self-harm or intentional overdose. The FCI model involves a series of telephonic follow-ups in the weeks and months following a patient’s discharge from the emergency department.

G0544 is a monthly billing code when furnishing FCI following a crisis encounter in the ED. Under the rule, CMS finalized several important billing requirements. The code is considered a “monthly bundle,” consisting of four calls per month, with each call lasting between 10-20 minutes, according to CMS.

Also, CMS clarified that G0544 can be provided by auxiliary personnel incident to the services of the billing practitioner, and that the patient’s discharge can come from locations other than the ED. The code “can be billed by practitioners in any instance in which the beneficiary has been discharged following a crisis encounter, including discharge from psychiatric inpatient care, or crisis stabilization,” CMS states.

Hospital Inpatient or Observation (I/O) Evaluation and Management (E/M) Add-on for Infectious Diseases

HCPCS code: +G0545

Descriptor: “Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases specialist, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and/or complex antimicrobial therapy counseling and treatment. (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, subsequent or discharge)”

2025 fee: $43.02

Key details: Eligible for billing by a “physician with specialized training in infectious disease,” G0545 is an add-on code that could be reported with hospital inpatient and observation codes 99221-99223 and 99231-99236, as well as discharge day management codes 99238-99239, which were originally left out of the proposal of coverage, according to CMS.

CMS is valuing the code “to capture the visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant that is not accounted for in the appropriate hospital inpatient or observation E/M base code billed by the infectious disease physician,” according to the agency.

The code includes specific, lengthy service elements, including “disease transmission risk assessment and mitigation,” “public health investigation, analysis and testing,” and “complex antimicrobial therapy counseling and treatment.” However, in the final rule CMS confirmed that “HCPCS code G0545 is intended to be used for one, or any combination, of the three proposed service elements.”

The code is not intended to be time-based, CMS says.

Interprofessional Health Record Assessment and Management

HCPCS codes: G0546, G0547, G0548, G0549, G0550, G0551

Descriptor:

• G0546 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient’s treating/requesting practitioner; 5-10 minutes of medical consultative discussion and review)
• G0547 ( … ; 11-20 minutes of medical consultative discussion and review)
• G0548 ( … ; 21-30 minutes of medical consultative discussion and review)
• G0549 ( … ; 31 or more minutes of medical consultative discussion and review)
• G0550 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a written report to the patient’s treating/requesting practitioner, 5 minutes or more of medical consultative time)
• G0551 (Interprofessional telephone/Internet/electronic health record referral service[s] provided by a treating/requesting practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, 30 minutes)

2025 fees: G0546 ($17.14), G0547 ($34.61), G0548 ($52.40), G0549 ($70.19), G0550 ($32.35), G0551 ($33.96)

Key details: CMS finalized coverage of six new HCPCS codes in an effort to expand its scope of covered behavioral health services. The four consult services (G0546-G0549) are time-based and cover lengths of time from 5-10 minutes to 31 minutes or more. The two health record assessment and referral services (G0550-G0551) are also time-based, with specific elements cooked into the code descriptors.

Providers will be required to obtain advance patient consent for the services. CMS also clarified that the treating/requesting provider and the consulting provider “do not have to be in the same organization to furnish interprofessional consultation services,” according to the final rule.

Digital Mental Health Treatment

HCPCS codes: G0552, G0553, G0554

Descriptor:

• G0552 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan)
• G0553 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month)
• G0554 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month. [List separately in addition to HCPCS code G0553])

2025 fees: G0552 (carrier-priced), G0553 ($51.75), G0554 ($39.79)

Key details: These proposed codes cover two therapeutic treatment management services (G0553 and +G0554) as well as a supply code for behavioral health treatment device (G0552). The therapeutic codes may be billed only when there is ongoing use of the digital mental health treatment (DHMT) device. Reporting the supply code G0552 comes with multiple preconditions:

• The DMHT device must cleared under section 510(k) of the FD&C Act or granted De Novo authorization by FDA.
• Supplying the device “must be incident to the billing practitioner’s professional services in association with ongoing treatment under a plan of care by the billing practitioner,” CMS says.
• For G0552 to be payable, the billing practitioner must incur a cost to acquire and furnish the DMHT device.
• The billing practitioner must diagnose the patient and prescribe or order the DMHT device.
• The patient would be eligible to use the device in an office or outpatient setting or in the patient’s home, depending on how the FDA has cleared the device for use.

In the final rule, CMS made several revisions to the code descriptors for G0553 and G0554 as a way to differentiate the services from remote therapeutic monitoring (RTM) codes. “We are finalizing refinements to HCPCS codes G0553 and G0554 to clarify that these codes are for treatment management with a DMHT device which is intended as a therapeutic intervention as opposed to RTM devices which, beginning January 1, 2024, will describe devices that may have a digital therapeutic intent as well as be intended to monitor response to a therapeutic intervention not necessarily delivered by an RTM device,” the rule states.

Advanced Primary Care Management Services

HCPCS codes: G0556, G0557, G0558

Descriptor:

• G0556 (Advanced primary care management services for a patient with one chronic condition [expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline], or fewer, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month … )
• G0557 (Advanced primary care management services for a patient with multiple [two or more] chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month … )
• G0558 (Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple [two or more] chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month)

2025 fees: G0556 ($15.20), G0557 ($48.84), G0558 ($107.07)

Key details: Multiple specialties and mid-level providers, including physicians, nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists, will be eligible to report the new advanced primary care management (APCM) services (G0556-G0558) that CMS finalized in the rule.

In the lengthy code descriptors that outline the elements of the APCM codes, they generally track with currently covered chronic care management (CCM) and principal care management (PCM) codes. For instance, the elements encompass initiation during a qualifying visit; 24/7 access for urgent needs; delivery of care in alternate ways, such as home visits or expanded hours; overall comprehensive care management; risk stratification of entire patient populations; performance measurement on quality, costs and certified EHR technology; and more. (Note: See Table 25: APCM Service Elements and Practice-Level Capabilities for the full list of required elements.)

CMS will not require that providers check the box on every single element in a reporting month; however, the capability to fulfill all listed elements should be there. “We anticipate that all the APCM scope of service elements (for example, comprehensive care management and care coordination) will be routinely provided, as deemed appropriate for each patient, acknowledging that not all elements may be necessary for every patient during each month (for example, the beneficiary may have no hospital admissions that month, so there is no management of a care transition after hospital discharge),” CMS states.

Consider another example: “In one month a patient with heart failure and chronic kidney disease receiving APCM Level 2 services (G0557) may be on a stable medication regimen, receive communication about their care plan, but no virtual check-ins. The next month, the patient may experience a heart failure exacerbation requiring inpatient admission, and then receive as part of their APCM service timely communication and follow-up with new labs ordered, multiple virtual check-ins ensuring that the patient understands their new medications, a phone call to help the patient understand the lab results, and an interprofessional consultation with the patient’s cardiologist to help decide if the patient’s diuretic dosage should be changed.”

Some practices, particularly those that are aligned in a value-based arrangement, will be in a better position to take advantage of the APCM services, CMS notes. For instance, practices in a Shared Savings accountable care organization (ACO) or those taking part in Innovation Center models, such as ACO REACH, Making Care Primary and Primary Care First, “will satisfy the performance measurement element of the APCM by meeting their respective program and model requirements,” the agency says.

Similar to the G2211 add-on visit complexity service that CMS activated in 2024, the expectation for the APCM codes is that they will “mostly be used by the primary care specialties, such as general medicine, geriatric medicine, family medicine, internal medicine and pediatrics,” CMS says, but acknowledges that other specialties often “function as primary care practitioners – for example, and OB/GYN or a cardiologist,” and in those cases they would be billing-eligible. However, eligible providers must meet a threshold of performing “all primary care services and [act as] the focal point for all needed care (the requirement for APCM),” CMS clarifies (emphasis added).

The agency anticipates that APCM services would typically be provided by clinical staff incident to the billing practitioner. CMS is considering the set of codes a “designated care management service,” which means it can be furnished by auxiliary personnel under general supervision.

The codes are not time-based. Rather, they would be reported once per calendar month provided the service requirements are met.

In brief, CMS is offering three levels of risk stratification for billing APCM codes, as follows:

• Level 1 (G0556): Patients with one or fewer chronic conditions.
• Level 2 (G0557): Patients with two or more chronic conditions.
• Level 3 (G0558): Patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries (QMB). (QMBs are, generally, low-income beneficiaries who comprise 66% of the 12.8 million dual-eligible population, according to CMS figures.)

“We anticipate that a practitioner using the advanced primary care model will bill for APCM services for all or nearly all the patients for whom they intend to assume responsibility for primary care,” CMS predicts.

CMS further notes several “duplicative” services that would not be billable by the same practitioner during the same time period as APCM services. That includes chronic care management (CCM), principal care management (PCM), transitional care management (TCM), interprofessional consultations, remote evaluation of videos or images, virtual check-ins and e-visits. However, CMS clarified in the final rule that a patient’s other health care providers can furnish and bill for other care management services, including TCM, CCM, PCM and others, during the same month.

Post-operative Care Services Add-on Code

HCPCS code: +G0559

Descriptor: “Post-operative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90- day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care … ”

2025 fee: $8.73

Key details: Addressing situations when a practitioner is involved in post-operative care after a surgical procedure performed by another practitioner, CMS finalized its determination to pay for such post-op care with an add-on code G0559.

“We recognize that there are comparatively more resource costs incurred when a practitioner who did not furnish the surgical procedure in a global package provides the follow-up care,” CMS states in the final rule.

Note that CMS would explicitly prohibit billing of the add-on code when the patient is seen by a practitioner in the same group practice. However, in a reversal from the proposal, CMS will allow a practitioner of the same specialty, as long as they are outside of the group practice, to report the add-on code.

“We understand that there may be instances where there is no formal coordination (i.e., to require billing of the transfer of care modifier -55) or no coordination at all between the proceduralist and the practitioner who provides post-operative care and expect that HCPCS code G0559 would be used in those instances,” CMS states. “We are finalizing HCPCS code G0559 with modification such that it may be billed by a practitioner of the same specialty as the proceduralist who is not in the same group practice as the proceduralist.”

Examples of the follow-up care that may arise include obtaining and reviewing documentation of the procedure, monitoring for infection or post-op complications. The add-on code would be billed along with an E/M visit that occurs during the 90-day post-op period will be eligible for reporting once during the post-op period.

Safety Planning Interventions

HCPCS code: G0560

Descriptor: “Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health or substance use disorder professionals or agencies; and making the environment safe”

2025 fee: $41.40

Key details: HCPCS code G0560 will establish separate payment for safety planning interventions addressing a patient’s risk of harm to themselves or others. The elements of the code involve various “coping strategies” and “sources of support” for individuals. Several elements, including “recognizing warning signs of an impending substance-use related crisis,” and “contacting mental health or substance use disorder professionals or agencies,” have been added to the code descriptor based on public feedback.

The agency made several critical clarifications in the final rule. The code will be effective as a standalone code effective Jan. 1, as opposed to an add-on code. Also, the code can be reported in 20-minute increments.

CMS noted that the code “would need to be personally performed by the billing practitioner for CY 2025,” and that opens the door to any practitioner who is authorized to furnish services for the diagnosis and treatment of mental illness, such as clinical social workers, mental health counselors, marriage and family therapists, clinical psychologists and physicians and non-physician practitioners.

The code is now added to the Medicare Telehealth list.

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Physician Fee Schedule Final Rule Archives 2021-2024 (old news)

2024 conversion factor

$32.7442 (updated 1/3/2024)

2023 conversion factor

$33.8872 (updated 1/5/2023)

• CMS continues to state it doesn’t have the authority to extend telehealth in all geographic locations after the PHE ends. Congress passed a law requiring Medicare to continue to pay for telehealth for 151 days after the PHE ends. This doesn’t require commercial payers to do the same.
• CMS tells us not to use POS 02 and POS 10 during the PHE. Continue to report the place of service that would have been reported if the patient was seen in person.

CMS is adopting most of the E/M CPT changes for 2023.

• However, when a patient is admitted from another site of service, CPT in 2023 now says to report both the first service (ED or office or nursing facility) and the initial hospital care code. CMS will not pay for both.
• CMS will continue its 8-24 hour policy for observation care.

Prolonged care coding is a mess.

• Not only are there two sets of codes: CPT and HCPCS codes, the time threshold for using them is different. Office visits have time ranges. For office visits, CPT allows us to use prolonged care when 15 minutes more than the lower of the time range. CMS requires the HCPCS code and only allows it when 15 minutes more than the higher of the time range.
• For inpatient, observation, and nursing facility prolonged care, CPT uses the times in the CPT book as the base for adding prolonged care. CMS is using the times in their internal time file and requires HCPCS codes.
• There is no CPT prolonged care code for home or residence services. CMS developed a HCPCS code.
• Need the details? Search for prolonged care in the search box for an article about this.

Split/shared visits

• Bill the service under the provider number of the practitioner who provided the substantive portion of the service.
• The substantive portion of the service may be determined by either who spent >50% of the time or the practitioner who documented in its entirety history, exam or MDM. Since history and exam are not key components, it is difficult to know what the “entirety” is.
• CMS had said that they would only use time in 2023, but they are allowing another “transition” year.

Critical care

• CMS is no longer applying the mid point rule to critical care for add-on code 99292. In order to use it, the full 30 minutes must be spent.

Screening for colorectal cancer

• This can now begin at age 45.
• If a patient has a positive screening stool test and is sent for colonoscopy, the colonoscopy can be reported and paid as screening, not diagnostic.

2022 Final Rule

2022 conversion factor—$34.6062

• Conversion factor decreased 3.75% from 2021 to 2022
• CMS posts complicated shared services rules for services performed in a facility
• Critical care updates
• CMS is developing a modifier for split/shared services and a new modifier for unrelated critical care by the surgeon in a global period, but did not release these modifiers in the Final Rule

Two new modifiers for 2021

FS  Split (or shared) Evaluation and Management service

• Use this for shared or split services between a physician and non-physician practitioner, including critical care

FT Unrelated Evaluation and Management (E/M) visit during a postoperative period, or on the same day as a procedure or another e/m visit. (report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated

• Use this for critical care performed by a surgeon during a global period. The critical care must be unrelated to the procedure/surgery done.
• The Final Rule also says the intensivist can use modifier FT (in addition to modifier 55) if there is a full transfer of care from the surgeon to the intensivist. Modifier 55 is for post operative management. It seems unlikely that a surgeon would fully transfer care to an intensivist for post op management.

November 6, 2021

CMS was right on time in releasing the 2022 Physician Fee Schedule Final Rule. It dropped November 2, 2021.

CMS stuck with their proposed conversion factor of $33.5983, a 3.75% decrease from last year and for anesthesia, the conversion factor is $20.9343, a 2.39% decrease. Last year, Congress stepped in the final hours of December and boosted the conversion factor. Certainly, the professional societies are advocating this, but who knows.

Shared or split services 2022

Most of us were waiting to see what CMS was going to do about shared services for E/M services performed in an outpatient department, inpatient, or ED setting. CMS added nursing facility to the allowed setting for shared services. Shared services are E/M services performed jointly between a physician and a non-physician practitioner (NPP). Shared services are currently allowed in an office setting only if they service also meets incident-to requirements.

Starting in 2022, shared services will no longer be allowed in place of service office, even if they meet incident-to rules.

Shared services will be allowed for nursing facility services, except for those services that are mandated to be done by a physician.Only a physician may bill the initial nursing facility visits 99304-99306 in a skilled nursing facility or nursing facility.  (There is an exception to this in a nursing facility who is not employed by the facility). Sometimes, the PA/NP sees the patient at an earlier date than the physician, who comes and does the admission. In that case, the PA/NP bills a subsequent visit, even though the initial has not been billed. This is a Medicare rule.

Critical care may be billed as a shared visit between a physician and NPP, but must be reported by the practitioner who provides >50% of the time.

I wrote about shared or split visits (or share/split as the AMA labels them) for 2022 in more detail here.

Critical care 2022

CMS had two proposals related to critical care. The first, mentioned above, is that a physician and NPP in a group may share critical care services. This is a change from their current policy. I’m going to call their new policy a win/lose situation.  Yes, you can add together the time of the physician and NPP (win) but you must bill it under the practitioner who has spent the most time (lose, if it’s an NPP, because it’s paid at 85% of the physician fee schedule.)

CMS has significantly changed its policies regarding critical care, and I will update CodingIntel’s critical care guide, webinar, quick video and the two articles about the topic.  But, here is the overview:

CMS is adopting CPT’s definitions and prefatory language for critical care services. Although CPT^® uses the term qualified health care professional, CMS continues to use the term non-physician practitioners. Both are describing advance practice registered nurses, clinical nurse specialists and physician assistants who are qualified to perform critical care in their state and organization. CMS says it is adopting the same list of bundled procedures as in the CPT book (old news, the same list was in their withdrawn manual portions.)

For services that cross midnight, CMS says it will follow the CPT^® rule in the introduction section that if the service is continuous past midnight, it does not reset at midnight and create a new hour. If there is a disruption, then when the service resumes after midnight, it starts a new hour.

CMS will now allow physicians/NPPs of different specialties to both provide critical care during the same time period. Their withdrawn manual section only allowed one practitioner to be paid for critical care at any one time.

Prior to 1/1/2022, one physician or NPP must have met the entire 74 minute time frame to bill 99291 before a second practitioner in the same group could report 99292 for an additional 30 minutes. So, if one pulmonologist spent 30 minutes and the second 50 minutes, the times could not be added together to report 99291 and 99292. Now, two practitioners of the same specialty can add together their time to meet 99291, and additional units of 99292.

Critical care may be shared between physicians and NPPs of the same specialty. Add together the time spent by each. Bill under the provider number of the practitioner who spent “a substantive portion” of the time, greater than 50%.

CMS will continue to allow an E/M service to be performed on the same day as critical care, if the E/M service occurred before the patient was critically ill, the patient later became ill later on the same calendar day. They removed the restriction that did not allow an ED visit and critical care to be billed on the same day by the same physician.

CMS will continue to allow surgeons to bill post-operative critical care that is unrelated to the surgery that was performed.

Check back to our critical care page for updates to all of the resources.

RHCs and FQHCs 2022

Rural Health Centers (RHCs) are pain an All Inclusive Rate (AIR) for medically necessary medical and mental health services and qualified preventive services on the same day (with a few exceptions). Federally Qualified Health Centers (FQHCs) are paid using the Prospective Payment System (PPS rate) for qualified visits.

Beginning January 1, 2022, a patient on hospice may elect as their attending physician a practitioner from an RHC or FQHC. A patient who is currently enrolled in hospice may change the attending designation after January 1.

CMS is allowing TCM and CCM to be done in the same calendar month, following their rules from prior years for other physician practices.

After the public health emergency ends, telehealth and audio only telehealth will be continue to be allowed for mental health services.  This is because of the CARES Act passed in March, 2020.  I’ll update the article on telehealth and update the articles on behavioral health care with these new rules. They extend to RHCs and FQHCs.

Teaching physician rules 2022

The ten pages of the rule related to billing for E/M services performed under the teaching physician rules didn’t provide any dramatic changes. CMS said:

• If using time to select an E/M service only the attending’s time (not the resident’s time) maybe included. This isn’t a change, but CMS clarified it is face-to-face time of the attending with the patient, and cannot include non-face-to-face activities or teaching.
• A commenter wanted CMS to use “provider-neutral” language instead of “teaching physician services” in order to include NPs and PAs who might spend time with residents. CMS said these clinicians are not included in the statutory definition of “physician.”
• For the primary care exception, only medical decision making can be used to select the level of E/M service.

Physician Final Rule 2021

Conversion factor for 2021 released–updated

January 6, 2021

In a typical year, the conversion factor is released in the physician fee schedule, and that’s that. This year, Congress passed a stimulus bill/continuing resolution in early December that mandated changes to the conversion factor. These are described in the next section. The important news is that on January 5, CMS released the calendar year 2021 conversion factor and it is $34.89. This is a decrease from the 2020 rate, but an increase of about 7.7% from the factor released in CMS’s final rule.

Combined with the increase in RVUs and payments for office and outpatient codes 99202–99215, groups that receive most of their revenue from office visits will see their Medicare revenue increase. And, surgical and procedural specialties will see less of a decrease than anticipated.

This comes from Congress adding $3 billion to Part B payments in 2021, and from prohibiting implementation of payment for the add-on code G2211, for inherent complexity.

Breaking news 12/22/20: health care changes in the stimulus bill

The stimulus bill/continuing resolution that Congress signed in the dead of night on Dec. 21, the shortest day of the year, includes health care provisions that change policy in the 2021 Physician Fee Schedule Final Rule.

• Implementation of add-on code G2211 for inherent complexity is delayed for three years
• The money that would have gone to primary care and medical specialties for G2211 will now be spread across all specialties, all services and will increase the conversion factor
• RVUs for office/outpatient codes will remain at the increased level that CMS published for 2021
• There is $3 billion dollars in additional funding to support a 3.75% payment increase
• The President signed the bill on Dec. 27th.

Overview of the 2021 calendar year Physician Fee Schedule Final Rule

• The Final Rule included a significant decrease in the conversion factor; with the passage of the stimulus bill/continuing resolution on Dec. 22, Congress is mandating an increase, partially based on delaying implementation of G2211, and partially by increasing funds for Part B payments
• Confirmation about teaching physician rules updated earlier in the year

CMS released the Final Rule for calendar year 2021 late December 1^st. If you’re reading this, you probably have already heard the main point.  The Dec 22 law  As expected, CMS confirmed their agreement with the 2021 AMA definitions and rules for codes 99202—99215.

With the increase in payments for office visits, CMS is also increasing payments for certain other services which have office visits as a component, or whose values were based on its similarity to a specific E/M service. This includes some ESRD monthly payments, maternity care, transitional care management, wellness visits, psychiatric collaborative care management, and assessment of cognitive impairment. CMS did not increase the value of services with 10 or 90 day global periods, which also include office visits.

Delayed for three years by Congress: HCPCS code G2211: add-on code for office visits

G2211 “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).”

This replaces the HCPCS placeholder code GPC1X that CMS talked about in prior rules, and we now have a definition and instructions on when to use it. CMS believes that even with the increase in RVUs for office visit codes, that the payments still do not reflect the complexity and expense associated with caring for patients in a primary care practice and certain other specialties. The increased payment is for the resources associated with:

“a comprehensive, longitudinal, and continuous relationship with the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.”[1]

CMS is not restricting its use to primary care, and specialists who care for a patient with a particular disease over a long period of time may also use it. It should not be used by professionals:

“whose relationship with the patient is of a discrete, routine, or time-limited nature, such as a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or and when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.”[2]

Based on that description, it would appear that the code would not have wide use in urgent care

Learn more about HCPCS code G2211 in this article.

HCPCS code G2212: prolonged care code for 99205 and 99215

CMS and the American Medical Association (AMA) disagreed about the time threshold to use the new CPT^® prolonged services code 99417. The office and outpatient codes 99202—99205, and 99212—99215 now have time ranges, not a single threshold time. 99417 is for 15 additional minutes beyond the usual time for use only with codes 99205 and 99215. However, when the AMA calculated when to use the add-on code 99417, they started counting at the lower time in the range and CMS started counting at the higher time in the range. Since they couldn’t agree, and the CPT^® books are already on our shelves, CMS developed a HCPCS code for prolonged care of 15 minutes over the maximum threshold time. Like 99417, it may only be reported with 99205 or 99215. Use G2212 and 99205 when 89 minutes were spent caring for the patient on the date of service (practitioner time only, direct care and non-face-to-face time). Use G2212 and 99215 when 69 minutes were spent.

HCPCS codes for virtual communication for clinicians who can’t bill E/M services

G2250, G2251

G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.)

G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion).

CMS developed these two new codes that are equivalent to existing HCPCS codes G2012 and G2010, for brief virtual communication and “store and forward” services done by physicians, advance practice registered nurses and physician assistants, clinicians who can bill for E/M services. CMS developed these similar codes G2250 and G2251 for social workers, psychologists, physical therapists (PT), occupational therapists (OT) and speech language pathologists (SLP). They may not be used by audiologists, because CMS believes that they are outside the benefit category for audiologists, and they may not be billed by for medical nutrition therapy.

In addition, HCPCS codes G2061—G2063 are replaced by CPT^® codes 98970—98972. These are on-line assessment codes for use by clinicians without E/M in their scope of practice. For PT, OT, and SLP services these are considered to be sometimes therapy codes and require modifier GO, GP or GN to signify that they are furnished as therapy services under a plan of care.

HCPCS code for virtual check in 11-20 minutes

G2252 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.)

This code has similar rules as G0210 and G2012, and is for longer time periods. When phone calls are no longer paid services after the end of the PHE, it could be used for phone calls.

Telehealth update

The rule includes a long section on telehealth, but isn’t likely to make anyone happy. CMS re-iterates its belief that it lacks statutory authority to continue the relaxed telehealth rules when the public health emergency is over. Specifically, during the PHE, CMS relaxed the requirement that the patient be in an underserved area, and must receive the telehealth service at a facility, an originating site. CMS believes that after the PHE ends, Congress must pass a law to allow telehealth to continue in its current form, to patients in any geographic area, from their home.

In multiple places in the rule, CMS confirms that when they say “real-time audio/visual communication” they require the use of both audio and visual technology, not audio only.  This is mentioned in relation to incident to supervision and the teaching physician rules. If you search (excluding audio-only) in the rule, you’ll get quite a few results.

CMS is not proposing to continue paying for audio only calls (phone calls) 99441—99443 after the end of the PHE (the end of the calendar year in which the PHE ends.) These codes will once again have a status indicator of bundled.

If both the patient and practitioner are in the same location, but using video equipment, CMS re-iterated their policy that this should not be reported as telehealth.

Teaching physician rules

CMS is allowing an attending to be present via real-time audio/visual communication in supervising an E/M service provided by a resident. The teaching physician must be present for the key/critical components using audio/visual communication. Phone is insufficient.  Notice what they say about documentation. CMS states that the patient’s medical record:

 “must clearly reflect how and when the teaching physician was present during the key portions of the service, in accordance with our regulations.”[3]

And, they have advice about what to do it the video call with the attending drops.

“We also expect that, if the teaching physician is virtually present and bills for services during which there is a disruption to the virtual connection between the teaching physician and the resident who is with the patient, the encounter would be paused until the connection resumes, or the appointment would be rescheduled.”[4]

CMS confirmed that under the primary care exception, the attending may supervise the service using audio/visual communication during the public health emergency.

The rule is about 2000 pages long, and I’m providing this first look summary. I’ll add information to relevant articles as I’m completing the 2021 site updates.

CMS developed a new prolonged services code: G2212 

Read about it in detail here: Prolonged services in 2021 with 99202–99215: 99417, G2212

Source citations

[1] 2021 Calendar Year Physician Fee Schedule Final Rule, page 275

[2] Final Rule, page 279

[3] Final rule, p. 320

[4] Final rule, p. 310

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Physician Fee Schedule Final Rule Archives 2019-2021 (old news)

For reference, we have included archives of previous year’s changes below.

2020 Physician Fee Schedule Final Rule

Summarized in this handout

2019 Physician Fee Schedule Final Rule

The 2019 Physician Final Rule was released right on time on November 1, 2018. By now, you’ve heard the news that CMS is not implementing its major change to a single blended rate for E/M levels 2-5 in 2019. I won’t repeat what you’ve already read in detail other places, but here are the highlights, and my thoughts.

Things CMS didn’t do:

• CMS did not finalize multiple procedure payment reduction for modifier -25. The proposal was to pay at 50% the lowest valued procedure when two procedures were reported and modifier 25 was on the claim. CMS did not finalize this. Both will continue to be paid at the full allowance. CMS did comment that they believe that there is an overlap in paying for an E/M and some minor procedures, because some of the work overlaps. (Rooming the patient, reviewing the patient’s history, instructions for care) This is good news for many specialties.
• CMS did not finalize a proposal that would allow two visits by physicians of the same specialty in one calendar day.
• And they didn’t change the codes used by Podiatrists. Podiatrists will continue to use E/M codes.

Postponed until 2021

• CMS is not implementing a single payment and single RVU value for levels 2-5 E/M codes. They say they will implement a changed version in 2021, which would pay one fee for level one patients, one fee for levels 2-4 and one fee for level 5 visits. (Varied by new or established patients). They did note that the AMA is working on changes.

“A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT^® coding definitions and guidance prior to our implementation, such as changes to MDM or code definitions that we could then consider for adoption.” (page 633 of the rule)

So, although CMS says that these E/M changes are finalized, if the AMA can make changes CMS finds acceptable, it is possible these would not go into effect. The difficulty is getting all of the specialties to agree.

• The two add-on codes for primary care and selected specialty services. CMS has developed the code description for these, and valued them, but is not implementing these until 2021. The rule didn’t say how this would be funded, and keep in mind that these type of changes need to be budget neutral to CMS.  CMS had planned on using the savings from the reduced payments for modifier 25.  CMS did add specialties that could report the inherent complexity E/M code, and say that both the primary care and specialty  codes could be used on the same claim, if a primary care provider was addressing a complex, specialty diagnosis. Let’s not spend too much time on how this would work until closer to 2021. They changed the valuation of these two codes to be the same, rather than having a lower value for the primary care service.
• The new prolonged services HCPCS code (30 minutes) is postponed until 2021.

Finalized proposals

• There is a new CPT^® code for chronic care management performed by the physician, NP or PA, 99491, and CMS is making this a payable code. (Why are the care management codes so difficult to find in the CPT^® book, and why don’t I put a tab on them?)
• CMS is recognizing the four existing and two new inter-professional consultation codes, 99446-99452. These look like a nightmare to me to document and bill, and for not much money.
• Using HCPCS codes, CMS will pay for a brief, virtual check-in (G2012) and for the provider looking at a pre-recorded image or video, “store and forward” (G2010). The wRVUs are low. G2012 could be billed only by clinicians who have E/M in their scope of practice for established patient visits. It could not be a result of an office visit in the past 7 days or result in an office visit in the next 24 hours, or next available appointment. Does a phone call count? Here’s what the rule says.

“We are persuaded by the comments advising us not to be overly prescriptive about the technology that is used, and are finalizing allowing audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. We note that telephone calls that involve only clinical staff could not be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”(Page 111 of the rule)  

As for the pre-recorded picture or video (please, no cat videos) this is a service that is used to determine if an office visit is needed. If it results in an office visit, then it is considered bundled and may not be billed. It may not be billed if the patient was seen in the last 7 days. It is for established patients only.

Changes to E/M: changes to reduce redundancy and provider burden

• The billing provider does not have to personally document the chief complaint or the HPI. Ancillary staff may record this, or it could be recorded on a form by the patient. The billing provider can note that it was reviewed and verified.
• For established patients, the provider does not need to re-enter information already in the record, as long as it is noted as reviewed and unchanged, or reviewed and updated. The provider may choose to focus on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the required elements. The practitioner should still review prior data, update if needed and indicate that this was done.
• Removal of duplicative requirements for notations when services are furnished with a resident.
• For home visits, the medical necessity for the home visit does not need to be stated in the note.

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