Doctors Face Payments Cut, New Primary Care, Dental, Digital Opportunities

In July, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule related to the 2025 Physician Fee Schedule (PFS), including a significant payment cut but additional opportunities in advanced primary care, dental services, digital therapeutics for mental health, and caregiver training.

Additionally, the rule proposes important changes for rural health clinics and federally qualified health clinics. This regulatory advisor article summarizes some of the key changes but does not include all provisions. Review the entire rule at Federal Register.

Payment provisions

CMS proposes a $32.36 conversion factor

The proposed conversion factor represents a 1% cut over CMS’ finalized 2024 conversion factor (32.74). However, in March, Congress stepped in to mitigate some of the cuts made to physician payments in the 2024 final rule, raising the conversion factor to $33.29 for services performed from March 9 to December.

This means if the 2025 conversion factor is finalized as proposed, physicians will see a 2.8% cut to payments in January unless Congress steps in again.

Evaluation and management (E/M) visits

In a welcome change from 2024, CMS proposes to allow payment of the E/M complexity add-on code when the base code (HCPCS G2211) is reported by the same practitioner on the same day as certain preventative services, including an annual wellness visit or vaccine administration. This change comes in response to commenters who expressed concern with CMS’ 2024 policy to exclude payment for the complexity add-on when the base code is reported with modifier-25.

Advanced primary care and enhanced care management

CMS’s Center for Medicare and Medicaid Innovation (CMMI) has more than a decade of experience testing over 50 innovative payment and care delivery models. Their focus has been to reduce program expenditures while preserving or enhancing quality of care for beneficiaries.

In response to insights gained from these innovative payment models, CMS is proposing to incorporate key payment and service delivery elements into permanent coding and payment under the PFS.

Specifically, CMS proposes to recognize advanced primary care, defined as “whole-person, integrated, accessible and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”

CMS is proposing three new HCPCS codes — GPCM1, GMCM2, and GPCM 3 — to reflect the new services:

HCPCS code	Descriptor
GPCM1	Advanced primary care management services 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 (Numerous requirements are proposed, which are too much to list here. Review the rule or reach out to CLA with questions.)
GPCM2	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, with the elements included in the GPCM1, as appropriate
GPCM3	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, with the elements included in GPCM1, as appropriate

CMS proposes these codes may only be reported once per calendar month, and only by the single practitioner serving as the focal point for all needed health care, in addition to being responsible for the patient’s primary care.

Addressing mental health crisis services

In the 2024 PFS proposed rule, CMS requested comment on whether there was a need for separate coding and payment for interventions furnished in the emergency department (ED) or other crisis settings for patients with a risk of suicide. Several commenters requested that Medicare enable wider implementation of Safety Planning Intervention (SPI) and Post-Discharge Telephonic Follow-Up Contacts Intervention (FCI). Commenters also noted a designated SPI code would make it easier to document SPI was provided.

SPI involves working with a patient to develop coping strategies and supports the patient can use in the event they experience thoughts of harm to themselves or others.

CMS is proposing to establish separate coding under the PFS for safety planning interventions.

HCPCS code

Description

GSPI1

Safety planning interventions, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health professionals or agencies; and making the environment safe; (List separately in addition to an E/M visit or psychotherapy)

In addition, CMS is proposing to create a monthly billing code to describe furnishing post-discharge follow-up contacts performed after discharge from an ED after a crisis encounter. The code will include four 10- to 20-minute calls in a month. The proposed code and descriptor is below.

HCPCS code	Description
GSPI1	Post-discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, per calendar month

Improving digital access to behavioral health services

To address challenges beneficiaries may have in locating mental health services, as well as recognizing digital therapeutics may offer means to access certain services, CMS is proposing three new HCPCS codes for digital mental health treatment (DMHT) devices, modeled after coding for remote therapeutic monitoring services.

HCPCS code	Description
GMBT1	Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan
GMBT2	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 data generated from the DMHT device from 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
GMBT3	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 data generated from the DMHT device from 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

The DMHT devices provided must be FDA approved. Digital platforms and applications marketed as behavioral health and wellness interventions are not included in the proposal as few have evidence of improved behavioral health outcomes.

In addition, CMS is proposing payment for six new G codes to reflect time spent by practitioners for interprofessional consultations between requesting providers and consultant practitioners.

Medicare payment for dental services

In prior years, CMS finalized payment for dental services when these services are integral to successful outcomes of Medicare-approved treatments. In 2025, CMS is proposing to add a dental or oral examination performed as part of a comprehensive workup, as well as medically necessary diagnostic and treatment services required to eliminate oral or dental infection prior to Medicare-covered dialysis services when used in the treatment of end-stage renal disease.

Payments for caregiver training

In the 2024 PFS, CMS finalized payment policies related to the training of caregivers without a patient’s presence. In response to comments requesting that the assessment of a caregiver’s knowledge be included in caregiver training, CMS is clarifying that when reasonable, assessing the skills and knowledge possessed by a caregiver can be included in CPT Code 96161, which is currently on the Medicare Telehealth List.

In addition, CMS is proposing new coding and payment for caregiver training for direct care services such as wound dressing changes, infection control, and techniques to prevent decubitus ulcer formation. Unlike existing caregiver training codes, the proposed codes focus on specific clinical skills that allow caregivers to provide hands-on treatment, reduce complications, and monitor the patient. Review the proposed codes:

HCPCS code	Description
GCTD1	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 dressing changes, and infection control) (without the patient present), face-to-face; initial 30 minutes
GCTD2	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 dressing changes, and infection control) (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) (Use GCTD2 in conjunction with GCTD1)
GCTD3	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 dressing changes, and infection control) (without the patient present), face-to-face with multiple sets of caregivers)

CMS is also proposing new coding and payment for caregiver behavior management and modification training. Existing coding allows for multiple-family group training, requiring training to be provided in a group setting. The new codes allow training for the caregivers of an individual patient.

HCPCS code	Description
GCTB1	Caregiver training in behavior management/modification for caregiver(s) of a patient 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
GCTB2	Caregiver training in behavior management/modification for caregiver(s) of a patient with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) (Use GCTB2 in conjunction with GCTB1)

Telehealth provisions

The proposed Medicare telehealth originating site facility fee is $31.04.

Codes on the Medicare Telehealth Services List are added under two categories: permanent and provisional. In the proposed PFS, CMS notes codes on the Telehealth Services List under the provisional status will remain under that status until CMS can complete a comprehensive analysis of all provisional codes in future rulemaking.

CMS proposes to remove one code with provisional status from the Telehealth Services List in 2025. Radiation treatment management (CPT code 77427) will be removed in response to commentary citing the importance of in-person physical examination to support quality of care.

CMS proposes adding thirteen new codes to the Telehealth Services List. If finalized as proposed, two codes related to PrEP for HIV (G0011, G0013) will be added to the list with a permanent status. n addition, one code related to home INR monitoring (G0248) and several codes related to caregiver training (97550-2, 96202-3, GCTD1-3, and GCTB1-2) will be added with provisional status.

Removing frequency limitations on telehealth subsequent care services

In the 2024 PFS final rule, CMS removed frequency limitations on the following codes whose limitations had been previously relaxed due to COVID-19. CMS is proposing to maintain the relaxed frequency limitations through December 31, 2025. Affected codes are related to hospital inpatient or observation care (99231-99233), subsequent nursing facility stays (99307-10), and critical care telehealth.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

Key proposed updates for RHCs and FQHCs include:

• Removing productivity standards for RHCs after feedback the standards were unrealistic for practitioners to reasonably meet.
• Requiring RHCs and FQHCs to bill Medicare for each of the services that comprise the care management HCPCS code G0511 to allow the development of additional data demonstrating service utilization. G0511 will no longer be payable when billed by RHCs and FQHCs. This may ultimately lead to lower reimbursement for some organizations if most of their care management services that are paid at a lower rate than G0511. To combat the impact of this change, RHCs and FQHCs will be allowed to bill add-on codes for additional time spent.
• Allowing RHCs and FQHCs to bill using proposed codes for APCM services, providing for certain telehealth policy extensions and rebasing the FQHC market basket to reflect 2022 base year

Medicare Shared Savings Program

CMS proposes several modifications to the Shared Savings Program. A few are summarized below:

• Introducing the APP Plus Quality Measure Set, and incremental growth of the APP Plus set to eleven measures over PY 2025-2028.
• Allowing ACOs to voluntarily terminate receipt of advance investment payments (AIPs) while continuing in the Shared Savings Program, as well as creating a process for ACOs to repay outstanding AIPs to CMS.
• Implementing a Health Equity Benchmark Adjustment to encourage ACOs to participate in service underserved communities. The HEBA would increase the likelihood that ACOs in underserved communities would earn shared savings.

Quality Payment Program

CMS is proposing to leave the performance threshold set at 75 points for the CY 2025 performance period.

MIPS Value Pathways (MVPs)

CMS is proposing six new MVPs for the 2025 performance year related to:

• Ophthalmology
• Dermatology
• Gastroenterology
• Pulmonology
• Urology
• Surgical Care

APP Plus quality measure set

CMS is proposing an additional quality measure set under the APP, similar to the quality measures proposed for MSSP. The six measures currently in the APP measure set are included, as well as five additional measures that will be phased into the set by 2028.

How CLA can help with understanding CMS rules

Trying to understand the potential impacts or opportunities related to the proposed PFS rule? Wondering about all the ways new CMS regulations could impact your organization? Our health care team can help provide guidance to providers across the health care continuum for regulatory, policy, and payment changes.

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