Tag: PFS

CMS Releases CY 26 PFS Proposed Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the physician fee schedule (PFS) for calendar year (CY) 2026.

Highlights of the proposal include:

  • Implementing the one-time 2.5% statutory increase included in the One Big Beautiful Bill Act.
  • Establishing two separate conversion factors: one for qualifying alternative payment model participants (QP) and another for non-qualifying physicians and practitioners.
    • The QP conversion factor would increase by 3.8% to $33.59.
    • The non-QP conversion factor would increase by 3.6% to $33.42.
  • Modifying several telehealth waivers, including:
    • Permanently removing the frequency limitations for subsequent inpatient visits, nursing facility visits and critical care consultations.
    • Permanently adopting a definition of direct supervision to include virtual presence via audio/video real-time communications technology.
      • Does not propose to continue allowing virtual supervision of residents when the service is performed virtually across all teaching settings; this would be allowed only for services provided in non-metropolitan statistical areas.
    • Extending the ability for federally qualified health centers and rural health clinics to bill telehealth services through Dec. 31, 2026.
  • Enhancing integration of behavioral health into primary care by:
    • Clarifying that marriage and family therapists and mental health counselors can bill Medicare directly for Community Health Integration and Principal Illness Navigation Services.
    • Creating add-on codes for Advanced Primary Care Management services that complement previously established Behavioral Health Integration or psychiatric Collaborative Care Model services.
    • Proposing deletion of the HCPCS code that describes social determinants of health risk assessment and altering language to refer to “upstream drivers” of health rather than “social determinants.”
  • Using new methodologies to calculate units of Medicare Part D drugs purchased under the 340B drug pricing program that must be excluded from the calculation of Medicare drug inflation rebates beginning Jan. 1, 2026, as required under the Inflation Reduction Act of 2022. The CMS proposes a claims-based methodology that would determine which Part D drug units are 340B eligible for exclusion. The CMS seeks comments on two methodologies: a prescriber-pharmacy methodology and a beneficiary-pharmacy methodology.
  • Implementing the Ambulatory Specialty Model, a mandatory payment model within selected core-based statistical areas, focused on specialists who frequently treat beneficiaries with congestive heart failure and low back pain, to begin Jan. 1, 2027, and run through Dec. 31, 2031.
  • Establishing a MIPS performance threshold of 75 points for the 2026 performance period through the 2028 performance period, as well as adopting six new MIPS Value Pathways (MVPs) and modifying performance categories under the Quality Payment Program. The new MVPs are proposed for the following:
    • Diagnostic radiology
    • Interventional radiology
    • Neuropsychology
    • Pathology
    • Podiatry
    • Vascular surgery
  • The CMS is seeking input on Executive Order 14192, “Unleashing Prosperity Through Deregulation.”

Hospitals are encouraged to contact Vickie Kunz by Sept. 2 regarding issues identified and submit comments to the CMS by Sept. 12. The MHA will provide an impact analysis in the coming weeks. A final rule is expected early November for the Jan. 1, 2026, effective date. Members with questions should contact Vickie Kunz at the MHA.

CMS Releases 2025 Physician Fee Schedule Final Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a issued a final rule to update the physician fee schedule (PFS) payment system effective Jan. 1, 2025.

The rule will:

  • Reduce the PFS conversion factor by a net 2.8% from the current $33.29 to $32.35 after expiration of the 2.93% statutory payment increase for 2024 and a 0% conversion factor update
  • Refine guidance regarding the complexity add-on code (G2211) to account for intensity and complexity for outpatient office (O/O) visits. Specifically, the CMS will allow payment of the O/O evaluation and management (E/M) visit complexity add-on code 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 Medicare Part B preventive service provided in the office or outpatient setting.
  • Modify supervision requirements for private practice outpatient therapy services from direct to general supervision for physical therapy assistants and occupational therapy assistants, improving access since physical and occupational therapists will no longer be required to physically be onsite for services performed by assistants.
  • Extend certain telehealth waivers through 2025 including:
    • Allowing providers to report enrolled practice addresses instead of home addresses when services are performed from their home.
    • Defining direct supervision to include virtual presence via audio/video real-time communications technology.
    • Virtual supervision of residents when the service is performed virtually across teaching settings.
    • Removing frequency limitations for subsequent care services in inpatient, nursing facility and critical care consultations.
  • Finalize proposals related to caregiver training services. Specifically, the CMS finalizes code descriptors for three caregiver training codes (G0541, G0542, G0543) and designated these as “sometimes therapy” services, facilitating payment for caregiver training services for outpatient physical therapy, occupational therapy and speech-language pathology services.
  • Finalize three new bundled codes (G0556, G0557, G0558) for Advanced Primary Care Management services effective Jan. 1, 2025. The CMS also finalized descriptors and levels of service as proposed stratified based on the number of chronic conditions and risk factors.
  • Update the data reporting period and phase-in of payment reductions for Clinical Laboratory Fee Schedule services. The final rule specifies Jan. 1 through March 31, 2026, as the reporting period with reporting required every 3 years. The final rule did not modify the Jan. 1 through June 30, 2019, data collection period. Payment reductions are limited to 0% for 2025 and 15% for each year 2026 through 2028.

Members with questions should contact Vickie Kunz at the MHA.

CMS Releases 2025 Physician Fee Schedule Proposed Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the physician fee schedule (PFS) payment system effective Jan. 1, 2025.

The proposal would:

  • Reduce the PFS conversion factor by a net 2.8% from the current $33.29 to $32.36 after expiration of the 2.93% statutory payment increase for 2024 and a 0% conversion factor update.
  • Refine guidance regarding the complexity add-on code (G2211) for payment of evaluation and management visits.

Extend certain telehealth waivers through 2025 including:

  • Allowing providers to report enrolled practice addresses instead of home addresses when services are performed from their home.
  • Defining direct supervision to include virtual presence via audio/video real-time communications technology.
  • Revise the data reporting period and phase-in of payment reductions for clinical laboratory tests under the clinical laboratory fee schedule by updating the data reporting period to Jan. 1 – March 31, 2025.
  • Extending the phase-in of payment reductions by an additional year meaning that 2024 payments cannot be reduced below 2023 amounts and 2025-2027 payments cannot be reduced more than 15% compared to the previous year.
  • Delay implementation of the CMS’ rebased and revised Medicare economic index until future rulemaking.
  • Codify policies established in revised guidance for Medicare Part B and Part D drug inflation rebate programs and propose new and revised policies for these programs.
  • Exclude suspected anomalous spending from financial calculation for the Medicare Shared Savings Program (MSSP).
  • Add six new measures to the MSSP measure set and streamline reporting options
  • Add six new optional merit-based incentive payment system value pathways for 2025.

The MHA encourages members to contact Vickie Kunz by Aug. 30, regarding issues identified. Hospitals are encouraged to review the proposed rule and submit comments to the CMS by Sept. 9.  The CMS is expected to release a final rule around Nov. 1, for the Jan. 1, 2025, effective date.  Members with questions may contact Vickie Kunz at the MHA.