On July 10, 2024, CMS released the 2025 Medicare Physician Fee Schedule proposed rule (Proposed Rule). This article summarizes key proposals concerning the Medicare Physician Fee Schedule that would impact allergy practices. Overall, the 2025 reimbursement rates for allergy services will decrease under the Proposed Rule.
The College continues to advocate for resolution to Medicare payment issues in partnership with the AMA and others. On July 24, we sent a joint letter to Congressional leaders advocating for specific changes in 2024.
To help you better understand the impact, the Advocacy Council developed a spreadsheet that compares the 2024 reimbursement and Relative Value Units (RVUs) for allergy codes to the ones proposed for 2025. (Note that these amounts do not account for geographic adjustments.)
The College’s Advocacy Council will submit comments to CMS – on the proposed changes noted below – prior to the Sept. 9 comment deadline.
Cuts to physician reimbursement
CMS is proposing to reduce the conversion factor to $32.3562, a decrease of $0.93 (or 2.80%) from the 2024 conversion factor of $33.2875. We continue to have concerns that the proposed cuts to provider payments will place an additional financial strain on practitioners. In our comment letter, we will urge CMS to work with Congress to mitigate or eliminate the effects of these cuts and identify long-term “fixes” to this annual issue.
Direct supervision
When a physician uses clinical staff to aid in the furnishing of a service, Medicare rules generally require that the physician be immediately available on site. This is known as direct supervision. In response to the COVID-19 public health emergency (PHE), CMS temporarily relaxed this direct supervision requirement, allowing the supervising physician (or other supervising practitioner) to be immediately available through real-time audio and video technology. CMS is proposing to continue this definition of direct supervision and to allow the presence and availability of the supervising practitioner through real-time audio and video communications through Dec. 31, 2025. The Advocacy Council has long advocated for the permanent adoption of this policy so that allergists can continue to satisfy the direct supervision requirement through the use of real-time audio and video technology.
For a subset of services, however, CMS is proposing to permanently adopt a definition of direct supervision that allows “immediate availability” of the supervising practitioner using real-time audio and visual interactive telecommunications (excluding audio only). Some of the services in this category that are relevant to allergists include:
- Services described by CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional).
- 95115 (Immunotherapy one injection).
- 95117 (Immunotherapy injections).
- 95044 (Allergy patch tests).
- 95012 (Exhaled nitric oxide measurement).
- 95052 (Photo patch test).
- 95056 (Photosensitivity tests).
Telehealth
Through emergency regulations in response to the COVID-19 PHE, CMS allowed the use of audio-only communications technology to furnish services described by the codes for audio-only telephone evaluation and management services and behavioral health counseling and educational services. In 2023, CMS extended the availability of telehealth services that can be furnished using audio-only technology and extended other PHE-related flexibilities including removal of the geographic and location limitations.
CMS now proposes to retire the originating site and geographic waivers at the end of 2024. Previously, these waivers allowed all patients, regardless of geographic location, to participate in telehealth services without the need to be physically present at a medical facility. Upon expiration of these waivers, patients will generally need to be present at a medical facility unless they are receiving substance use disorder or mental health treatments, or are in a rural area medical setting.
Beginning Jan. 1, 2025, CMS is proposing that an “interactive telecommunications system” include two-way, real-time audio-only communication technology for certain telehealth services furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology. CMS recognizes there is variable broadband access in patients’ homes, and that even when technologically is feasible, patients simply may not wish to engage with their practitioner in their home using interactive audio and video. A CMS designated modifier must be appended to the claim, verifying that the conditions for these services have been met. If CMS implements its proposal to let the geographic and originating site waivers expire at the end of 2024, this updated clarification on “interactive telecommunications system” will only be relevant for patients receiving mental health or substance use disorder treatments.
In addition, CMS now acknowledges the shift in practice patterns toward models of care that include the practitioner’s home as the distant site and believes it appropriate to continue site billing flexibility as CMS considers various proposals that may better protect the safety and privacy of practitioners. Therefore, through 2025, CMS is proposing that the agency will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home.
Office/Outpatient evaluation and management (E/M) visits
In the 2024 Medicare Physician Fee Schedule final rule (2024 Final Rule), CMS finalized separate payment for the HCPCS code G2211 (Complexity add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established). This E/M visit complexity add-on code is intended to reflect the inherent complexity of the visit that is derived from the longitudinal nature of the patient-practitioner relationship. In the 2024 Final Rule, CMS also finalized a policy that this code is not payable when the office/outpatient E/M visit is reported with CPT Modifier -25, which indicates a significant, separately identifiable office/outpatient E/M visit by the same physician or other qualified health care professional on the same day as a procedure or other service.
Beginning in CY 2025, CMS is proposing to allow payment of HCPCS code G2211 when the office/outpatient 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 furnished in the office or outpatient setting.
Requiring manufacturers of certain single-dose container or single-use package drugs to provide refunds with respect to discarded amounts
Current law requires drug manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package for calendar quarters beginning Jan. 1, 2023. CMS is proposing to amend the definition of “refundable single-dose container or single-use package drug” by including “single-patient-use container” as a package type term and adding three types of products that may be considered refundable. These are:
(1) Product furnished from a single-dose container or single-use package based on FDA-approved labeling or product information.
(2) Product furnished from an ampule for which product labeling does not have discard statement or language indicating the package type term, like “single-dose container,” “single-use package,” “multiple-dose container,” or “single-patient-use container”.
(3) Product furnished from a container with a total labeled volume 2 ml or less for which product labeling does not have language indicating the package type term, like “single-dose container,” “single-use package,” “multiple-dose container,” or “single-patient-use container.”
Overpayment
Under circumstances where additional time is needed to investigate or calculate overpayments for Medicare Parts A and B, CMS proposes to allow suspension of the existing 60-day timeline. Rather, providers and practitioners would be required to report and return overpayments within the sooner of 1) 180 days after identifying the overpayment, or 2) after calculating overpayment aggregates upon conclusion of the investigation.
Read more information about the 2025 Medicare Physician Fee Schedule proposed rule.
- Physician Payment Schedule Fact Sheet
- Medicare Shared Savings Program Fact Sheet
- Quality Payment Program (QPP) Fact Sheet
The College’s Advocacy Council will submit comments to CMS – on the above proposed changes – prior to the Sept. 9 comment deadline.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
