07/11/2024

CMS Released Medicare Fee Schedule and the Quality Payment Program Proposed Rule for 2025

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) proposed rule for Calendar Year (CY) 2025. CMS also released the CY 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule.

These proposals include updated payment rates, telehealth flexibilities, and provisions addressing health equity, behavioral health, prior authorization, and reimbursement for cell and gene therapies. The Association for Clinical Oncology (ASCO) continues to assess the proposals, but based on a preliminary analysis, key provisions for the cancer care community include:

Physician Fee Schedule

Conversion Factor
The proposed 2025 Resource-Based Relative Value Scale (RBRVS) conversion factor (CF) for physician services is $32.3562. This represents a decrease of 2.8% from the final CY 2024 RBRVS CF of $33.2875. Additionally, the proposed 2025 Anesthesia CF is $20.3340, which represents an approximately 2.1% reduction from the final 2024 Anesthesia CF of $20.7739.

The proposed physician CF update is primarily based on three factors:

• A statutory 0% update scheduled for the PFS in 2025
• A 0.05% positive budget neutrality adjustment
• The expiration of funding patches passed by Congress through the Consolidated Appropriations Act, 2023, and the Consolidated Appropriations Act, 2024, which partially mitigated cuts to the CF for 2023 and 2024

Specialty Impact
As a result of policy proposals and coding changes in the proposal, CMS estimates a 0% overall impact for both the hematology/oncology specialty and the radiation oncology specialty in 2025. This does not reflect the 2.8% reduction in the CF. The actual impact on individual clinicians will vary based on geographic location and the mix of billed Medicare services.

The proposed reimbursement cuts coincide with an ongoing increase in the cost of practicing medicine. CMS projects that the Medicare Economic Index (MEI) will increase 3.6% for 2025, which is why ASCO supports H.R. 2474, the Strengthening Medicare for Patients and Providers Act, which would provide a permanent, annual reimbursement update equal to the increase in the MEI and allow physician practices to invest in new strategies for providing high-quality, equitable care.

Telehealth
CMS is proposing to make audio-only services available to Medicare beneficiaries beginning January 1, 2025. An interactive telecommunications system would include two-way, real-time, audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.

CMS is also proposing that, through 2025, it will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home.

CMS’s proposal would continue to permit virtual direct supervision to auxiliary personnel when required. The agency is also proposing temporary extensions of virtual supervision for a broader range of services when teaching physicians virtually supervise telehealth services provided by residents in teaching settings.

During the COVID-19 public health emergency, CMS had the authority to expand access to telehealth services for all Medicare beneficiaries. A temporary extension, waiving the geographic and site restrictions on telehealth reimbursement, is scheduled to expire at the end of 2024. Without Congressional action, starting January 1, 2025, patients with Medicare will need to be in a rural area and at a medical facility to receive non-behavioral health services via telehealth.

Office/Outpatient (O/O) Evaluation and Management (E/M) Visits
For 2025, CMS is proposing to allow payment of the O/O E/M visit complexity add-on code G2211—which was finalized in the 2024 PFS final rule—when the O/O E/M base code is reported by the same practitioner on the same day as an annual wellness visit, vaccine administration, or any Part B preventive service furnished in the office or outpatient setting.

Community Health Integration Services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services
CMS is not proposing any changes to the codes for community health integration, social determinants of health risk assessment, or principal illness navigation services; however, the agency is interested in feedback from stakeholders on potential refinements for CMS to consider in future rulemaking. CMS is specifically requesting information on other factors not adequately captured in current coding and payment for these services and how these codes are being furnished with community-based organizations. It also seeks information to improve rural use.

Expanding Colorectal Cancer Screening
CMS is proposing to update and expand coverage of colorectal cancer (CRC) screening by removing coverage of barium enema as a method of screening and in its place, CMS is proposing to expand coverage for Computed Tomography (CT) Colonography. Building upon policies finalized in the 2023 PFS, CMS is also proposing that either a positive Medicare-covered blood-based biomarker test or a non-invasive stool-based test is part of the CRC screening continuum and the follow-on colonoscopy would not incur beneficiary cost-sharing.

Quality Payment Program

Merit-Based Incentive Payment System Performance Threshold
CMS is proposing to maintain the MIPS performance threshold at 75 points for all three MIPS reporting options: traditional MIPS, MIPS Value Pathways (MVPs), and Alternative Payment Model Performance Pathways (APPs). Clinicians must reach a score of more than 75 to avoid a reimbursement penalty of up to 9%. CMS is also proposing to maintain the quality data completeness criteria at 75 through the 2028 performance period.

MIPS Value Pathways
CMS is proposing six new MVPs for reporting in the 2025 performance year including ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. Beginning in the 2026 performance period, multispecialty groups won’t have the option to report an MVP at the group level, and instead would need to participate at the subgroup, individual, or (if applicable) APM Entity level.

The agency would calculate all available population health measures for an MVP participant and apply the highest scoring population health measure to their quality performance category score. If the proposal is finalized, MVP participants would no longer be required to select a population health measure as part of their MVP registration.

Hospital Outpatient Prospective Payment System

Updates to OPPS and ASC payment rates
Every year, CMS reviews and updates payment rates and policies for the OPPS and ASC payment systems. For 2025 CMS is proposing to increase OPPS payment rates by 2.6% for hospitals that meet quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3%, reduced by 0.4 percentage points for the productivity adjustment.

Using the proposed hospital market basket update, CMS also proposes to increase the ASC rates for 2025 by 2.6% for ASCs that meet quality reporting requirements.

Prior Authorization
CMS is proposing to shorten the review timeframes for the Hospital Outpatient Department prior authorization process from 10-business days to 7-calendar days for standard reviews. Although Medicare fee-for-service (FFS) is not an impacted payer under the CMS interoperability and prior authorization final rule, CMS is also proposing to align the FFS prior authorization review timeframe for standard reviews with the timeframes in that rule. CMS is not proposing any changes to the expedited prior authorization review timeframe in FFS, which is currently 2-business days (instead of the 72-hours in the interoperability and prior authorization rule).

CMS did not add any additional services to those that require prior authorization. CMS currently requires prior authorization for blepharoplasty, rhinoplasty, botulinum toxin injections, panniculectomy, vein ablation, cervical fusion with disc removal, implanted spinal neurostimulators, and facet joint interventions.

Cell and Gene Therapy Reimbursement
In 2023, the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel approved four new Category I CPT codes for the harvesting, preparation, and administration of chimeric antigen receptor T-cell (CAR-T) therapy, which will replace existing Category III CPT codes beginning January 1, 2025. CMS is not proposing to reimburse the first three codes for harvesting and preparation of cells – 3X018, 3X019, and 3X020 under OPPS. CMS is, however, proposing a payment rate of $327.68 for code 3X021 for the administration of CAR-T only.

Additionally, CMS proposes excluding CAR-T and other cell and gene therapies (Table 1 in the proposed rule) from packaging under Comprehensive Ambulatory Payment Classification (C-APC) when they appear on the same claim as the primary C-APC service. CMS will reimburse these drugs on pass-through status for one year—CY 2025—to collect information from stakeholders.

Access to Non-Opioid Treatments for Pain Relief
CMS is proposing to provide temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) and ASC settings from January 1, 2025, through December 31, 2027. CMS is proposing that seven drugs (Table 84) and one device qualify as non-opioid treatments for pain relief, and it proposes these products be paid separately in both the HOPD and ASC settings.

Medicaid, Children’s Health Insurance Program (CHIP), Drug Shortages, 340B
CMS is proposing a continuous 12-month eligibility period for children under age 19 in Medicaid and the Children’s Health Insurance Program (CHIP). Furthermore, CMS is proposing equity measures in the hospital outpatient, ASC, and rural emergency hospital quality program measure sets, in addition to provisions aimed at eliminating Medicare enrollment barriers for individuals returning to the community from incarceration, among others.

CMS did not propose any policy changes to address prescription drug shortages or 340B drug pricing.

ASCO will continue to analyze these and other provisions in the proposed rules and will submit comments to CMS.

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