Key Digital Health Implications of the 2025 Medicare Physician Fee Schedule

Overview

• The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2025.
• The final rule largely finalizes provisions in the July proposed rule, expanding the services on the Medicare Telehealth Services List and extended some temporary telehealth and virtual care flexibilities.
• Notably, CMS finalized coverage for dispensing and monitoring of innovative digital mental health technologies and advanced primary care management service codes, which include the use of digital health modalities to improve care coordination. 

General Telehealth-Related Provisions

• On a provisional basis: Caregiver training and safety planning interventions [CPT codes 97550, 97551, 97552, 96202, 96203 and HCPCS codes G0541-G0543 (GCTD1-3) and G0539-G0540 (GCTB1-2)]; and,
• On a permanent basis: Individual counseling for pre-exposure prophylaxis for Human Immunodeficiency Virus (HIV) (HCPCS codes G0011 and G0013).

New CPT Codes for Audio-Visual and Audio-Only Telehealth Services. The final rule reiterates that CMS will not recognize new synchronous audio-video or audio-only CPT codes finalized by the CPT Editorial Panel for telehealth services provided to Medicare patients at this time. CMS accepted the CPT Editorial Panel’s replacement of the G2012 code with 9X091 for brief virtual check-ins between a practitioner and patient, given the similarity between the two codes.

The CPT Editorial Panel also proposed deleting three codes (99441–99443) for reporting telephone evaluation and management (E/M) services. In the final rule, CMS notes that these codes are each assigned provisional status on the Medicare Telehealth Services List and will return to bundled status when current telehealth flexibilities related to audio-only services expire on December 31, 2024.

Audio-Only Communication Technology. CMS finalized its expanded definition of an interactive telecommunications system to include audio-only technology, but only in cases where the patient is unable or does not consent to the use of video.

Interprofessional Consultation. CMS is finalizing the addition of six new interprofessional consultation codes that may be billed by providers who cannot independently bill Medicare for E/M visits (e.g., clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors). Treating/requesting practitioners must obtain patient consent prior to initiating an interprofessional consultation.

• Distant Site Requirements: Practitioners may continue to bill using their currently enrolled practice site instead of their home address when the practitioner’s home is the distant site for a telehealth visit.
• Direct Supervision via Use of Two-way Audio/Video Communications Technology: Physicians and other practitioners may continue to conduct direct supervision via a virtual presence through real-time audio and visual interactive telecommunications for certain services that are required to be furnished under supervision of a physician or other supervising practitioner. Further, CMS is finalizing that a supervising physician or practitioner may provide such virtual direct supervision (1) for services furnished incident to a physician or other practitioner’s professional service, when provided by auxiliary personnel employed by the billing physician or supervising practitioner and working under his or her direct supervision (using appropriate codes and modifiers); and (2) for office or other outpatient visits for the evaluation and management of an established patient who may not require the presence of a physician or other qualified health care professional.
• Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations: CMS continued the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing visits, and critical care consultations.
• Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs). CMS is continuing to define “direct supervision” within FQHCs and RHCs to include audio-video communications technology (excluding audio-only) for FQHCs and RHCs. CMS is also finalizing its proposal to temporarily allow payment for non-behavioral health visits furnished via telehealth through the end of 2025 using HCPCS code G2025, and will continue delaying the in-person visit requirement for mental health services delivered via communication technology by FQHCs and RHCs to beneficiaries in their homes until January 1, 2026.
• Teaching Physician Billing for Services Involving Residents with Virtual Presence: Teaching physicians may continue to have a virtual presence (via real-time audio-visual observation, excluding audio-only) in all teaching settings, but only in clinical instances when the service is furnished virtually.

Note: Without Congressional action, geographic and originating site flexibilities that have been in place since the onset of the COVID-19 pandemic are set to expire at the end of 2024.

Telehealth Originating Site Facility Fee Payment Amount Update. CMS finalized an increase to the telehealth originating site facility fee payment to $31.04 for CY 2025.

Telehealth Place of Service Code. CMS will continue to pay the non-facility PFS rate telehealth services billed with POS 10 (telehealth provided in a patient’s home) in CY 2025 and beyond.

Advanced Primary Care Management Provisions

In an effort to accelerate the adoption of value-based payment models for primary care, CMS finalized the adoption of the following three new HCPCS codes for the provision of Advanced Primary Care Management (APCM) services. The new APCM codes incorporate elements of several existing care management and communication technology-based services into a bundle of services that reflects the essential elements of the delivery of advanced primary care (e.g., Principal Care Management, Transitional Care Management, and Chronic Care Management.)

• G0556 – Level 1: Patients with one or fewer chronic conditions.
• G0557 – Level 2: Patients with two or more chronic conditions.
• G0558 – Level 3: Patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries.

Unlike other primary care management codes previously adopted by CMS, the new APCM codes may be billed monthly without time-related billing restrictions. This will encourage practitioners and clinical staff to use digital health technologies to improve care management and coordination.

Behavioral Health-Related Provisions

Digital Mental Health Treatment Devices. CMS finalized coverage of digital mental health treatment (DMHT) devices through the use of a three-code series of HCPCS codes, which are used in conjunction with ongoing behavioral health care treatment and modeled off codes used for remote therapeutic monitoring (RTM):

• The first, G0552, may be used for “supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan.” The practitioner must diagnose the patient and prescribe or order the DMHT device, incident to the practitioner’s ongoing treatment of the patient under a plan of care by the billing practitioner.
• Two other codes will support the follow-on use of DMHT devices. G0533 will be used for the first 20 minutes of treatment management services related to the use of the DMHT device, and G0544 for subsequent 20-minute intervals. These codes require at least one interactive communication with the patient, or the patient’s caregiver, during the calendar month. Pricing for the codes is based on pricing for the comparable treatment management services for RTM.

Telecommunication Flexibilities for Periodic Assessments and Initiation of Treatment with Methadone. CMS finalized the ability for practitioners to furnish periodic assessments for methadone treatments via audio-only starting January 1, 2025, as long as all other applicable requirements are met and the use of these technologies are permitted under the applicable Substance Abuse and Mental Health Services Administration and Drug Enforcement Administration requirements. CMS also finalized allowance of the opioid treatment program intake add-on code (HCPCS code G2076) to be furnished via two-way audio-video communications technology when billed for the initiation of methadone.

Safety Planning Interventions (SPI) and Post-Discharge Telephonic Follow-up Contacts Intervention (FCI). CMS finalized, with modifications, its proposed payment mechanisms and coding for SPI and related services, including follow-up calls that may reduce suicidal behaviors and are important in lowering attempts at suicide and deaths. Specifically, CMS finalized HCPCS code G0560 as a standalone code rather than an add-on code as proposed, and the code will be used for 20-minute billing intervals. G0560 must be personally performed by the billing practitioner for CY 2025, but CMS will continue to consider this issue for future rulemaking.

FCI is a specific protocol of services for individuals in the community with suicide risk to reduce the potential for adverse outcomes following discharge from the emergency department and other relevant care settings. CMS finalized payment for the FCI HCPCS code G0544 as a monthly bundle.

Next Steps

The majority of provisions in the final rule will take effect on January 1, 2025. Stay tuned for further action from Congress to extend other temporary telehealth flexibilities set to expire at the end of 2024 (e.g., geographic and originating site restrictions).