ADVOCACY ALERT: CMS Releases 2025 Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System Proposed Rule

• By: admin
• On: 07/11/2024 20:44:56
• In: Advocacy

Medicare Physician Fee Schedule Conversion Factor

CMS's proposed conversion factor for 2025 is estimated to be $32.3562, which takes into account the statutorily required update to the conversion factor of 0 percent and removal of the temporary 2.93 percent payment increase provided by Congress for services furnished from March 9, 2024, through Dec. 31, 2024.

The conversion factor represents a 2.8 percent decrease from the 2024 MPFS conversion factor of $33.2875.

The proposed cut to the conversion factor can only be stopped by Congress. In June, ASNC wrote to the Senate Finance Committee asking Congress to provide physicians with an annual payment update, beginning in 2025, that would be tied to the Medicare Economic Index (MEI), which is projected at 2.6 percent for 2025. ASNC also expressed urgency on reforming budget-neutrality requirements to avoid cuts to the conversion factor and significant fee schedule redistribution in the future.

Radiopharmaceuticals Furnished in Physician Offices

CMS issued a point of clarification confirming that, for radiopharmaceuticals furnished in settings other than hospital outpatient departments, Medicare Administrative Contractors would determine payment limits for radiopharmaceuticals based on any methodology in place on or prior to November 2003, including the use of invoice-based pricing. This clarification accompanies CMS's proposed hospital outpatient radiopharmaceutical payment policy outlined below.

Cardiovascular Risk Assessment and Management 

CMS is proposing coding and payment for atherosclerotic cardiovascular disease (ASCVD) risk assessment and risk management services. The ASCVD risk assessment would be performed in conjunction with an evaluation and management visit when a practitioner identifies a patient at risk for but without a diagnosis of CVD.

The risk assessment tool would include demographic data, modifiable risk factors for CVD, possible risk enhancers, and laboratory data. The output would be required to include a 10-year estimate of the patient's ASCVD risk. CMS is also proposing coding and payment for ASCVD risk management services that include service elements related to CVD risk reduction, such as blood pressure and cholesterol management, for beneficiaries at medium or high risk (>15 percent in the next 10 years) for CVD.

Hospital Outpatient Update

CMS proposes an update to HOPPS payment rates by 2.6 percent. This increase is based on the projected hospital market basket increase of 3.0 percent reduced by a 0.4 percentage point productivity adjustment.

Packaging for Diagnostic Radiopharmaceuticals

CMS is proposing to change the way it pays for diagnostic radiopharmaceuticals. Currently, costs associated with diagnostic radiopharmaceuticals are packaged into payments for the nuclear medicine tests with which they are associated. CMS now proposes reforming the current bundling policy to pay separately for any diagnostic radiopharmaceutical with a per-day cost greater than $630 and removing these diagnostic radiopharmaceutical costs from the payment amounts for nuclear medicine tests. 

Any radiopharmaceutical with a per-day cost below the $630 threshold would remain bundled. This would apply to many radiopharmaceuticals used in SPECT and PET procedures. 

CMS's proposal follows mounting pressure to unbundle radiopharmaceuticals from nuclear medicine test payments. Stakeholders who favor unbundling argue current packaging policies are limiting patient access to more innovative diagnostic radiopharmaceuticals.

Diagnostic radiopharmaceuticals that exceed the $630 per-day cost threshold would be assigned to an ambulatory payment classification (APC), making those radiopharmaceuticals specified covered outpatient drugs. Because few radiopharmaceutical manufacturers currently report average sales price (ASP) data for their products, or because that data is not current, CMS believes it would be more appropriate to pay for separately payable diagnostic radiopharmaceuticals based on their mean unit costs taken from hospital claims data as a proxy; however, CMS would consider using ASP data in the future.

ASNC is assessing the impact of the proposed policy on the nuclear medicine APCs.

Details to Come 

ASNC will comment in response to these and other proposals. Please refer to the following documents: 

• CY2025 Medicare Physician Fee Schedule Proposed Rule
• CY2025 Medicare Physician Fee Schedule Proposed Rule Fact Sheet
   
• CY2025 Hospital Outpatient Prospective Payment System Proposed Rule
• CY2025 Hospital Outpatient Prospective Payment System Fact Sheet
  

ASNC's advocacy team is, as always, working for you and will keep you informed