The Centers for Medicare and Medicaid Services (CMS) has released multiple proposed rules for calendar year (CY) 2025.

2025 Medicare Physician Fee Schedule

CMS has released the proposed CY 2025 Medicare Physician Fee Schedule (PFS). The CY 2025 Proposed Conversion Factor (CF) is: $32.3562. This represents a 2.79% reduction from the 2024 CF.

The proposed reduction is the result of the expiration of two short-term funding patches and a positive budget neutrality adjustment of .05%. Congressional action is required to avoid or mitigate this reduction.

Telehealth

While CMS is maintaining some flexibility on virtual supervision, they state in their press release on the proposed rule that:

However, absent Congressional action, beginning January 1, 2025, the statutory restrictions on geography, site of service, and practitioner type that existed prior to the COVID-19 PHE will go back into effect. After that date, people with Medicare will need to be in a rural area and a medical facility to receive non-behavioral health services via Medicare telehealth.

New Fascial Plane Block Codes

ASRA Pain Medicine and the American Society of Anesthesiologists (ASA) brought forward six new facial plane block codes. For the 10 codes in the code family, CMS is proposing the RUC recommended work RVUs for all 10 codes. They are also proposing the RUC recommended practice expense (PE) inputs for CPT codes 6XX08, 6XX09, 6XX10, 6XX12, 64487, 64488, and 64489 with only minor revisions for CPT codes 6XX07, 6XX11, and 64486. The full discussion can be found on pages 148-149 of the proposed rule.

View the CY 2025 Medicare PFS Proposed Rule here.

2025 Hospital Outpatient and Prospective Payment System and Ambulatory Surgery Center Payment System

CMS also released the CY 2025 Hospital Outpatient and Prospective Payment System (OPPS) and Ambulatory Surgery Center (ACS) Payment System proposed rule. CMS is proposing to update hospital outpatient payments by 2.6%. A couple initial items are highlighted below from the press release and fact sheet and a more in-depth analysis will be forthcoming.

Access to Non-Opioid Treatments for Pain Relief

According to the fact sheet,

CMS is proposing to implement Section 4135 of the Consolidated Appropriations Act (CAA), 2023, which provides temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) and ASC settings from January 1, 2025, through December 31, 2027. This proposal would implement several statutory provisions including evidence requirements for medical devices and the FDA-approved indications that meet the statutory requirements. To implement the statutory payment limitation under which the additional payment must not exceed the estimated average of 18% of the OPPS payment for OPPS service or group of services with which the non-opioid treatment for pain relief is furnished, CMS is proposing to utilize the top five OPPS procedures by volume for each nonopioid drug or device to calculate the payment limitation. Finally, CMS is proposing to initially assign a payment offset of zero dollars for the qualifying non-opioid products, as maintaining the non-opioid portion of the procedure payment rate better aligns with the overall intent of the non-opioid policy to ensure access is not hindered by Medicare payment policies.

We are proposing that seven drugs and one device qualify as non-opioid treatments for pain relief, and we propose these products be paid separately in both the HOPD and ASC settings starting in CY 2025. We are soliciting comment and supporting documentation from interested parties on additional products that may qualify for separate payment under this provision starting in CY 2025. 

Prior Authorization

The proposed rule states,

Changes to the Review Timeframes for the Hospital Outpatient Department (OPD) Prior Authorization Process: We are changing the current review timeframe for prior authorization requests for OPD services from 10-business days to 7-calendar days for standard reviews.

The hospital OPD services require prior authorization for blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, implanted spinal neurostimulators, cervical fusion with disc removal, and facet joint interventions.