The healthcare industry is in constant flux, and staying abreast of the latest Medicare billing rule updates is paramount for healthcare providers. As we navigate 2025, several significant changes have come into effect, impacting reimbursement, telehealth services, care delivery models, and compliance requirements. This blog post aims to provide a comprehensive overview of these updates to help healthcare professionals adapt and ensure accurate billing practices.
Key Changes in the 2025 Medicare Physician Fee Schedule (PFS)
The Centers for Medicare & Medicaid Services (CMS) has released the Calendar Year (CY) 2025 Revisions to Payment Policies under the Medicare Physician Payment Schedule (PFS) and Other Changes to Part B Payment and Coverage Policies final rule. Here are some of the critical updates you need to be aware of:
1. Reduction in the Conversion Factor
One of the most significant changes is the reduction in the PFS conversion factor. For 2025, the conversion factor has been finalized at $32.35, a decrease of $0.94 (2.83%) from the 2024 amount of $33.29 (which was temporarily increased from the initial $32.74). This reduction will impact physician reimbursement across various specialties. While the Medicare Economic Index (MEI) projects a 3.5% increase in the cost of practicing medicine for 2025, this payment cut poses a financial challenge for many healthcare providers.
2. Telehealth Policy Adjustments
While some telehealth flexibilities introduced during the COVID-19 pandemic have been extended, there are crucial adjustments to note:
- Geographic Restrictions: The waiver of geographic restrictions, which allowed beneficiaries to receive telehealth services from any location, has expired. This means that originating sites will generally revert to pre-pandemic rules, although some exceptions exist, particularly for behavioral health services.
- Originating Site: Patients’ homes are generally no longer valid originating sites for most telehealth services, except for specific behavioral health services which remain exempt from geographic restrictions and can be delivered via audio-only platforms.
- Telehealth Providers: The temporary allowance for all Medicare providers to deliver telehealth services has also expired, meaning only eligible provider types can furnish these services now.
- Frequency Limitations: The suspension of limitations on telehealth frequency for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations continues.
- Audio-Only Services: CMS will not reimburse deleted CPT codes 99441–99443 for audio-only visits. Instead, new codes 98000–98015 have been introduced for audio and video visits, with the exception of 98016 (virtual check-in), which replaces G2012 and will be reimbursed.
- Virtual Supervision: The ability for teaching physicians to have a virtual presence for services involving residents in all teaching settings when the service is furnished virtually has been extended for one year.
3. New and Revised CPT/HCPCS Codes
Several new and revised codes have been introduced, impacting various aspects of care:
- Community Health Integration (CHI) Services: New CPT codes for initial assessments and follow-up visits to address broader health needs within communities, such as coordinating with resources for housing, food, or transportation assistance.
- Social Determinants of Health (SDoH) Risk Assessment: New CPT codes for initial assessments and follow-up visits to identify and address social factors impacting patient health, like housing or food insecurity.
- Principal Illness Navigation (PIN) Services: Three new time-based HCPCS codes for initial visits, follow-up visits, and non-face-to-face care management communication for patients with serious or complex health conditions.
- Caregiver Training Services: New G-codes (G0541-G0543) for caregiver training in direct care services and supports (e.g., preventing pressure ulcers, wound care) and for behavior management and modification training (G0539-G0540). These services are also added to the Medicare Telehealth List on a provisional basis.
- Cardiovascular Risk Assessment and Management: New G-codes (G0537 for 5-15 minute assessments and G0538 for ongoing risk management for high-risk patients).
- Post-Operative Care Management: New G-code for post-operative care during the 90-day global period when managed by a provider who did not perform the surgery.
- Advanced Primary Care Management (APCM): A new series of G-codes (G0556, G0557, G0558) for different levels of care management for patients with chronic conditions, emphasizing 24/7 access, care planning, and coordination. These codes do not have time-based thresholds.
- Interprofessional Consultations: New HCPCS codes (G0546–G0551) to facilitate consultations between treating/requesting practitioners and consultant practitioners, particularly in mental health specialties.
- Standalone Code for Health Behavior Assessment and Intervention: HCPCS code G0560 will be a standalone code (not an add-on) and can be billed in multiple 20-minute units when performed with psychotherapy or an Evaluation and Management (E/M) service.
- Virtual Check-in: Code 98016 replaces G2012 for virtual check-ins.
4. Changes for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Effective July 1, 2025, RHCs and FQHCs will no longer be able to bill the bundled G0511 code for care management services. Instead, they must bill individual care management codes, aligning with traditional ambulatory practices. This change is part of broader Medicare billing rule updates aimed at improving tracking and recognition of the specific care services provided. Additionally, RHCs and FQHCs can now bill for Part B preventive vaccines (pneumococcal, influenza, hepatitis B, COVID-19) during patient visits and for both medical and dental services provided on the same day (using the KX modifier to indicate medical necessity for dental services).
5. G2211 Code Expansion
The G2211 code can now be billed with office/outpatient E/M visits (99202–99205, 99211–99215) when provided on the same day as Annual Wellness Visits (AWV), vaccine administration, and Medicare Part B preventive services.
6. Complex Non-Chemotherapy Drug Administration
CMS clarifies that certain biologics and infusion drugs can be billed using chemotherapy administration codes (96401–96549) when appropriate, such as for rheumatology-related conditions.
7.Billing for Services by Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs) in Private Practice
Therapists in private practice can now bill and receive Medicare payments for services provided by PTAs and OTAs even when the supervising therapist is not physically present in the office or patient’s home.
Impact on Healthcare Providers
These Medicare billing rule updates will have a multifaceted impact on healthcare providers:
- Revenue Adjustments: The reduction in the conversion factor will likely lead to decreased reimbursement for many services, requiring practices to review their financial projections and potentially identify areas for efficiency improvements.
- Telehealth Strategy Adaptation: Providers will need to adjust their telehealth service delivery models to comply with the reinstated geographic and originating site restrictions. However, the continued flexibilities for behavioral health and the new codes for virtual care offer opportunities for continued remote service provision.
- Increased Administrative Burden: The introduction of numerous new codes and the changes for RHCs/FQHCs will necessitate staff training and updates to billing and coding processes to ensure accurate claim submissions.
- Focus on Integrated Care: The new codes for CHI, SDoH risk assessment, and APCM highlight Medicare’s emphasis on addressing the holistic needs of patients, encouraging providers to integrate social determinants of health and care coordination into their practices.
- Opportunities for Enhanced Reimbursement: The new codes for caregiver training, cardiovascular risk assessment, and advanced primary care management may offer opportunities for increased reimbursement for services that address critical aspects of patient care.
- Importance of Accurate Documentation: With the evolving coding landscape, precise and comprehensive documentation will be more critical than ever to support the medical necessity and accurate billing of services.
- Need for Continuous Learning: Staying updated with ongoing clarifications and future policy changes from CMS will be essential for all healthcare providers and their billing teams.
Conclusion:
The 2025 Medicare billing rule updates represent a significant shift in how healthcare services are reimbursed and delivered. By staying informed, investing in training, and adapting their practices, healthcare providers can navigate these changes successfully, ensure compliance, and continue to provide high-quality care to Medicare beneficiaries. The emphasis on integrated care, telehealth, and addressing social determinants of health signals a move towards a more holistic and patient-centered approach to healthcare delivery within the Medicare system.