CMS rolls out final payment rules for physicians, outpatient facilities, ASCs, home health, and renal dialysis services

In addition to finalizing payments for providers, the Centers for Medicare & Medicaid Services (CMS) said the rules will help strengthen primary and patient-centered care, reduce maternal mortality, and advance health equity.

CMS on Friday released the 2025 final rules for the Medicare Physician Fee Schedule (PFS), Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC), the Home Health Prospective Payment System, and the End-Stage Renal Disease (ESRD) Prospective Payment System.

Final physician payment rule

In an announcement for the Medicare Physician Fee Schedule Final Rule, CMS finalized its proposal to cut Medicare physician reimbursement by 2.93 percent. The finalized 2025 PFS conversion factor is $32.35, a decrease of $0.94 from the current conversion factor.

RELATED: HHS: Proposed physician payment rule cuts doc pay but strengthens primary care

CMS said the rule also aims to strengthen primary care, expand access to preventive services, and further access to whole-person care for services such as behavioral health, oral health, and caregiver training. Among the changes:

• Adopts new coding and payment policies for advanced primary care management services, such as 24/7 access to care and care plan development. CMS said the codes for these services are stratified based on patient medical and social complexity. The policies incorporate lessons learned via the Innovation Center value-based primary care models, and represent the beginnings of a new permanent pathway toward accountable care in the PFS, according to the agency.
  
  
• Finalizes a method for adjustments to account for the impact of improper payments when reopening an ACO’s shared savings and shared losses calculations and to mitigate the impact of significant, anomalous, and highly suspect billing activity in CY 2024 or subsequent calendar years on annual ACO financial reconciliation.
  
  
• Adds six new Merit-based Incentive Payment System Value Pathways that address ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.
  
  
• Adds new coding and payment for Food & Drug Administration-cleared digital mental health treatment devices, safety planning interventions that can help prevent suicides and overdoses, and services to better integrate behavioral health with primary care. 
• Improves access to services in opioid treatment programs, including social determinants of health assessments, coordinated care and referral services, patient navigational services, and peer recovery support services.
  
  
• Finalizes payment for certain dental services associated with dialysis services for the treatment of end-stage renal disease, including for persons undergoing chemotherapy, head and neck cancer treatment, and transplantation. 
• Provides payment for caregiver training services related to direct care services and supports as well as new policies that will allow caregiver training services to be provided virtually.
  
  
• Expands coverage of the hepatitis B vaccine for people with Medicare who have not received the hepatitis B vaccine or whose vaccination status is unknown, at no cost to the individual. This will enable people with Medicare to get the hepatitis B vaccine from pharmacies and also allows pharmacies and mass immunizers to roster bill Medicare consistent with current billing for flu, pneumococcal, and COVID-19 vaccines.
  
  
• Updates and expands coverage of colorectal cancer screening to promote access and remove barriers for much needed cancer prevention and early detection, especially within rural communities and communities of color. 
  
  
• Preserves limited flexibilities to telehealth services, including allowing certain practitioners to provide direct supervision via a virtual presence of auxiliary personnel, when required, virtually through immediate availability via real-time, audio-video technology. It will allow temporary extensions for teaching physicians to be present virtually when they furnish telehealth services involving residents in teaching settings.

Hospital outpatient and ASC payment rule

The Hospital OPPS and ASC Payment System Final Rule for 2025 updates payment rates for 3,500 hospitals and approximately 6,100 ASCs. Next year they will receive a 2.9 percent pay bump, a slight increase from the proposed rate of 2.6 percent.

RELATED: 2025 OPPS Proposed Rule is out: CMS pitches policies to reduce maternal mortality, advance health equity, and support underserved communities

In addition, the rule addresses the maternal health crisis, health disparities, access to behavioral health, and improve transparency in the health system. Among the changes:

• Implements new health and safety requirements for hospitals and critical access hospitals providing obstetrical services. The provisions set baseline standards for the organization, staffing, and delivery of care within obstetrical units, update the quality assessment and performance improvement (QAPI) program, and require staff training on evidence-based maternal health practices. 
  
  
• Finalizes policies to reduce the use of opioids and to increase access to high-cost drugs in tribal communities. CMS will provide additional payment for certain non-opioid drugs and medical devices for pain relief that have FDA-approved indications to reduce post-operative pain or produce postsurgical analgesia, and medical devices that have demonstrated they reduce opioid usage when used in the postoperative setting. Medicare will make an additional payment for Indian Health Services (IHS) and tribal hospital outpatient departments to increase access to high-cost drugs, such as those involved in treating cancer. 
  
  
• Removes barriers to ensure that people with Medicare who are on bail, parole, probation, home detention, or who are required to live in halfway houses, can access Medicare services. The agency will also expand eligibility criteria for a special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or who are on bail, parole, probation, home detention, or live in halfway houses, to further support these individuals.

“Together, these policies meaningfully impact health disparities by addressing equity and access barriers for underserved communities,” said Dr. Meena Seshamani, deputy administrator and director of CMS’ Center for Medicare, in an announcement. “Patients deserve access to post-operative pain relief that can decrease their exposure to opioids, access to the care that will help bridge vulnerable transitions from incarceration to the community, and access to the care that will help fight their cancer, in every community across our country. This rule takes a significant step forward in reducing disparities and increasing access to care.”

Home health payment rule

CMS also issued the 2025 Home Health Prospective Payment System final rule, which updates Medicare payment policies and rates for home health agencies. The agency estimates that Medicare payments to home health agencies will increase in the aggregate by 0.5 percent or $85 million compared to calendar year 2024.

RELATED: CMS proposes 2025 payment system rules for home health

The updated rates include the final CY 2025 home health payment update of 2.7 percent ($445 million increase), which is offset by an estimated 1.8 percent decrease that reflects the permanent behavior adjustment ($295 million decrease) and an estimated 0.4 percent decrease that reflects the updated FDL ($65 million decrease).

Other changes finalized in the rule include:

• Updates to the CY 2025 intravenous immune globulin (IVIG) items and services’ payment under the IVIG benefit.
  
  
• Updates to the Home Health Agencies’ (HHA) Conditions of Participation (CoPs) to reduce avoidable care delays by ensuring that referring entities and prospective patients can select the most appropriate HHA based on their care needs.
  
  
• Establishes a new standard that requires HHAs to develop, implement, and maintain, through an annual review, a patient acceptance-to-service policy that is applied consistently to each prospective patient referred for home health care. The policy must address the anticipated needs of the referred prospective patient, the HHA’s caseload and case mix, the HHA’s staffing levels, and the skills and competencies of the HHA staff. HHAs must make available to the public accurate information regarding the services offered by the HHA and any service limitations related to types of specialty services, service duration, or service frequency. The HHA must review this information as frequently as the services are changed, but no less often than annually.
  
  
• Collect four new items in the social determinants of health category in the HH Quality Reporting Program, including one living situation item, two food items, and one utilities item. 
  
  
• Changes all-payer data collection to begin with the start of care OASIS data collection timepoint instead of the discharge timepoint.