Industry News, February 2025

​On Friday, January 31, 2025, a bipartisan coalition of lawmakers reintroduced a bill aimed at counteracting and surpassing a recent pay reduction for physicians that took effect at the beginning of the year. The Medicare Patient Access and Practice Stabilization Act of 2025, effective April 1, 2025, would continue the 2.83 percent Medicare pay reduction for services provided from January through March. However, starting April 1, 2025, through December 31, 2025, the legislation would implement a 6.62 percent increase, offsetting the previous payment cut and the impact of the first quarter’s reductions while adjusting for inflation. 

Bill Proposed to Boost Physician Pay April through December 2025

The lawmakers highlighted the broader consequences of Medicare payment cuts, warning of reduced access to care in rural and underserved areas, physician layoffs, office closures, and increased burnout. Additionally, the Centers for Medicare & Medicaid Services (CMS) projects a 6.4 percent increase in practice costs, exacerbating the strain on medical providers.

This same measure was introduced in  October 2024, but it failed to pass before Congress adjourned in January 2025. This legislation has gained support from over 150 provider organizations, trade groups, and lobbying associations.

The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare policy, has also called for a revision to the current pay cuts. However, their recommendation would replace the existing system with a single update based on the Medicare Economic Index (MEI) or practice cost inflation minus one percentage point, alongside safety-net add-on payments that are not budget neutral. ​

The American Medical Association (AMA), a key advocate for Medicare payment reform, reported inflation-adjusted Medicare reimbursement for physician services has declined by 33 percent since 2001. Over the same period, payments have increased by just 7 percent while medical practice costs have risen by 59 percent. 
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"This legislation would begin to reverse the cuts physician practices have endured over the last four years, all while dealing with high inflation," said AMA President Bruce A. Scott, M.D. in a press release. "As this bipartisan bill demonstrates, lawmakers recognize that the current trend is unsustainable and, if unaddressed, will harm patients. Ensuring access to care and supporting practice sustainability is a national issue requiring urgent congressional action." 

The Medical Group Management Association (MGMA) has also called for swift passage of the bill. In a press statement, the organization emphasized the financial hardships resulting from Congress’s failure to reverse the 2025 Medicare fee schedule cuts: "These cuts have jeopardized the viability of Medicare-funded practices, commercial contracts linked to Medicare rates, and Medicaid reimbursements in states using Medicare as a benchmark." ​

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CMS Clarifies Complex Drug Administration for A/B MACs

In the 2024 proposed Physician Fee Schedule rule, The Centers for Medicare & Medicaid Services (CMS) sought public feedback on payment concerns related to non-chemotherapeutic complex drug administration services. The agency intended to address concerns from stakeholders that existing Medicare billing and coding guidelines were insufficient for capturing the complexities involved in administering non-chemotherapy drugs, particularly infusion therapies, leading to potential underpayment or denials. Commenters, including the American Society of Hematology (ASH), recommended that CMS adhere to the CPT® coding guidelines and framework outlined in the CPT® codebook, emphasizing that these guidelines adequately describe the administration of drugs and biologics.

Effective January 1, 2025, CMS finalized a policy update to the Medicare Claims Processing Manual, Chapter 12, Section 30.5. This revision aligns coding language with Current Procedural Terminology (CPT®) code definitions for complex non-chemotherapy infusion procedures. Specifically, CMS clarifies that the administration of certain drugs and biologics may be classified as complex and appropriately reported under chemotherapy administration CPT® codes 96401–96549. The updated language in the Medicare Claims Processing Manual explains:

​“A/B MACs should consider multiple factors when determining if the level of intensity for a complex drug administration service has been met, rather than just the drug name alone. Chemotherapy administration is considered highly complex and requires physician or qualified health professional work and monitoring well beyond the level of the therapeutic, prophylactic, and diagnostic injections and infusions code series (96360-96379) due to the high incidence of potentially adverse reactions for the patient. This service typically requires direct supervision from qualified health professionals and/or clinical staff with advanced practice training in the special considerations of preparation, dosage, and disposal and often involves frequent monitoring of the patient and conferring with a physician.” 

​This update ensures that Medicare Administrative Contractors (MACs) have the necessary guidance to correctly process claims for non-chemotherapy complex drug and biologic administration. 

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Replacement of Medicare’s MIPS Program

The Merit-based Incentive Payment System (MIPS) was established by the Centers for Medicare and Medicaid Services (CMS) through the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. As part of the Quality Payment Program (QPP) under MACRA, MIPS was intended to financially reward Medicare providers (who are reimbursed under Medicare Part B covered professional services) for patient care improvement from volume-based care to value-based care. This is through the use of a combined performance score of 0-100 based on four categories: quality measures, cost measures, promotion of interoperability. and practice improvement activities. Eligible Medicare providers that meet or exceed MIPS measure thresholds receive a payment bonus while those providers that do not meet or exceed those thresholds receive a penalty or no adjustment. There is a two-year gap between a performance reporting year and a payment year. For the 2025 reporting year/2027 payment year, the threshold remains at 75 points. This program is designed to be budget-neutral, meaning the funds available cannot exceed the penalties imposed. 

Several studies and medical association evaluations, including a 2022 study by the American Medical Association (AMA), evaluated MIPS scores of more than 80,000 primary care providers for 3.4 million patients. Findings revealed MIPS scores were “inconsistent related to performance on process and outcome measures,” meaning MIPS may not be a reliable indicator of a physician’s clinical performance or an effective way to incentivize quality improvement among U.S. physicians.

Key issues in the current MIPS measurement design include physicians who are often penalized for providing high-quality  care to sicker or marginalized patients; smaller practices and rural-based practices struggling to meet MIPS requirements are often penalized more than larger health-system-backed physician practices; and MIPS measurements are more relevant to primary care than other specialties. According to CMS’ 2022 Quality Payment Program Experience, 27 percent of small physician practices were penalized, 18 percent of rural physician practices were penalized, nearly 30 percent of physicians in solo practice received the maximum 9 percent penalty, and anesthesiology and orthopedic surgery were among specialties with the highest proportion of physicians receiving a penalty.

In addition, MIPS presents a heavy financial and administrative burden for physician practices. In a  2021 study by the AMA, 30 physician practices across the U.S. were interviewed. Findings revealed an average of $12,811 per physician was spent to be MIPS compliant, and 202 hours per year was spent on MIPS-related activities. 

Currently, there are three MIPS reporting options available: traditional MIPS, Alternative Payment Model (APM) Performance Pathway (APP), and MIPS Value Pathways (MVPs). As the newest MIPS reporting option, CMS created the MVPs program as an alternative to eventually replace MIPS. The groundwork for the MVPs program includes a subset of measures and activities related to certain specialties and medical conditions, such as emergency medicine, oncology, cardiology and vascular surgery, just to name a few. In addition, each MVP includes population health measures promoting inoperability performance category objectives and measures and potential physician specialty recommendations so physicians recognize the best-suited MVP for their reporting. 

As CMS continues to develop and maintain the MVPs program, MVPs reporting is optional. However, CMS intends to sunset traditional MIPS through future rulemaking and encourages early adoption of MVPs reporting so physicians can get familiar with the program before reporting through MVPs becomes mandatory.  

Key issues in the current MIPS measurement design include physicians who are often penalized for providing high-quality  care to sicker or marginalized patients; smaller practices and rural-based practices struggling to meet MIPS requirements are often penalized more than larger health-system-backed physician practices; and MIPS measurements are more relevant to primary care than other specialties. According to CMS’ 2022 Quality Payment Program Experience, 27 percent of small physician practices were penalized, 18 percent of rural physician practices were penalized, nearly 30 percent of physicians in solo practice received the maximum 9 percent penalty, and anesthesiology and orthopedic surgery were among specialties with the highest proportion of physicians receiving a penalty.

In addition, MIPS presents a heavy financial and administrative burden for physician practices. In a  2021 study by the AMA, 30 physician practices across the U.S. were interviewed. Findings revealed an average of $12,811 per physician was spent to be MIPS compliant, and 202 hours per year was spent on MIPS-related activities. 
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Currently, there are three MIPS reporting options available: traditional MIPS, Alternative Payment Model (APM) Performance Pathway (APP), and MIPS Value Pathways (MVPs). As the newest MIPS reporting option, CMS created the MVPs program as an alternative to eventually replace MIPS. The groundwork for the MVPs program includes a subset of measures and activities related to certain specialties and medical conditions, such as emergency medicine, oncology, cardiology and vascular surgery, just to name a few. In addition, each MVP includes population health measures promoting inoperability performance category objectives and measures and potential physician specialty recommendations so physicians recognize the best-suited MVP for their reporting. 

As CMS continues to develop and maintain the MVPs program, MVPs reporting is optional. However, CMS intends to sunset traditional MIPS through future rulemaking and encourages early adoption of MVPs reporting so physicians can get familiar with the program before reporting through MVPs becomes mandatory.  ​

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CMS Issues 2025 Telehealth FAQ

​The Centers for Medicare and Medicaid (CMS) issued a new frequently asked questions (FAQ) for calendar year (CY) 2025. The Medicare physician fee schedule (MPFS) proposed and final rules published annually are the means by which CMS makes the telehealth changes for the ensuing year. This document can be found on the CMS website under Telehealth. 

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CMS and NCHS Announce ICD-10 Updates Effective April 1, 2025

​The Center for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS) have announced the ICD-10-CM and ICD-10-PCS updates which will be effective April 1, 2025. There are two annual updates for ICD-10, October and April. October updates are typically more extensive than the April updates.

Diagnosis Codes

For ICD-10-CM, there are no new diagnosis codes, but there are verbiage changes to the Alphabetic Index and Tabular List that may impact coding. Guidelines have also been updated accordingly to reflect these changes. The following is a summary of some of the main changes to be noted.

​Tabular List
A “Use Additional Code” instructional note has been added under the following codes, indicating that an additional diagnosis code should be assigned to the medical record, as appropriate:

• (A15-A19) Tuberculosis
• E23.0 Hypopituitarism
• J65 Pneumonoconiosis associated with tuberculosis
• K72 Hepatic failure NEC
• K73 Chronic hepatitis NEC
• K90.822 Short bowl syndrome without colon in continuity
• N18 Chronic kidney disease
• O26.64 Intrahepatic cholestasis of pregnancy

​An “Excludes 1” and/or “Excludes 2” note has been added or deleted under the following codes, indicating conditions that may or may not be reported together:

• K56.41 Fecal Impaction
• K90.82 Short bowel syndrome
• (S00 – T88) Injury, poisoning and certain other consequences of external causes ​

Alphabetic Index
Revisions, additions, and deletions have been made to the corresponding main terms in the alphabetic index including:

• Decrease and Dissection
• Infection, infected, infective (opportunistic)
• Myocarditis
• Pneumocystis and Pneumonia

​The updated code files for April 2025 are to be used for discharges and patient encounters occurring from October 1, 2024, through September 30, 2025. The ICD-10-CM files can be found on the CMS website or the CDC website.

Inpatient Procedures

For ICD-10-PCS, there are 50 new procedure codes being implemented, 12 procedure code deletions, and 2 title revisions. Of interest for radiation therapy is a new table for a Stereotactic Radiosurgery procedure of the heart and great vessels under section D, “Radiation Therapy”; specifically, code D228DZZ, Stereotactic other photon radiosurgery of conduction mechanism.

A complete listing of the new PCS codes with their corresponding MS-DRGs can be found here. With these additions, the total of ICD-10-PCS codes for 2025 is now 78,948. The updated code files for April 2025 are to be used for discharges occurring from October 1, 2024, through September 30, 2025. The ICD-10-PCS code files can be found on the CMS website.  

Along with the PCS code updates  are the ICD-10 MS-DRG Version 42.1 Grouper Software, Definitions Manual Table of Contents, and the Definitions of Medicare Code Edits Version 42.1 Manual. This manual accommodates these new procedure codes and is available on the CMS website under MS-DRG Classifications and Software.

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Payment in Cancer Navigation

When the Centers for Medicare & Medicaid Services (CMS) released new Principal Illness Navigation (PIN) billing codes to reimburse oncology practices by providing patient navigation services for 2024, there was an expectation that practices could now receive reimbursement for the work done to help patients with the challenges of their cancer journey. Research has consistently shown that patient navigation services help reduce hospitalizations, lower costs, and bridge survival disparities across racial groups. 

However, nine months into utilizing PIN codes, many practitioners find that securing payment is more challenging than anticipated. This was the consensus among panelists during a session at the Patient-Centered Oncology Care® (PCOC) 2024 Conference hosted by the American Journal of Managed Care® (AJMC). In the session, titled "The New Math: What Does PIN Mean to the Enhancing Oncology Model?”, the discussion featured experts experienced with CMS’ Enhancing Oncology Model (EOM), which focuses on value-based, patient-centered care for cancer patients receiving chemotherapy based on six-month episodes of care.

The panelists agreed the effectiveness of patient navigation is significant. Originally funded by grants, patient navigation has now been incorporated into business models. Studies show that incorporating social workers, dietitians, and genetic counselors significantly improves patient care, reinforcing the idea holistic management not only benefits patients but also reduces costs. 

While the introduction of PIN codes is a positive step, panelists noted challenges: 

​· PIN codes require a full hour of service for billing, whereas navigation services are typically delivered in shorter increments. Principal care management (PCM), by contrast, allows billing in 30-minute increments and includes tasks like handling prior authorizations. 

​· Telehealth, which became a primary navigation tool during the pandemic, is not eligible for PIN reimbursement, which is a major limitation for practices relying on virtual care. 

· Some Medicare patients are facing high co-pays, which practices are obligated to collect, sometimes leading them to forego navigation billing altogether. 

​The panel expressed hope that CMS would reconsider some of these restrictive rules and believes the oncology community should persist in advocating for better implementation of PIN billing.  

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