CMS Proposes Reduced Physician Payments in 2025; Maintains Anesthesiology Quality Payment Program Features

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule, which includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). Within the fee schedule, CMS proposed Medicare payment cuts to the Anesthesia Conversion Factor that will only compound the financial strain that anesthesia groups are already facing. The proposed rule has a 60-day comment period. Final regulations will be issued on or around November 1 and unless otherwise noted, policies will be effective on January 1, 2025.

ASA opposes these additional Medicare payment cuts included in the CY 2025 PFS proposed rule. The proposed rule underscores how the Medicare payment system is broken, especially during a time when anesthesia groups are faced with continued inflation pressures. ASA has already launched an initiative to engage legislative stakeholders and regulatory agencies to minimize and reverse these cuts that negatively impact anesthesiologists.

Fee Schedule Provisions:

The 2025 proposed anesthesia conversion factor (CF) is $20.3340, representing a decrease of 2.1% from the 2024 anesthesia CF of $20.7739. The 2025 proposed RBRVS CF is $32.3562. This represents a decrease of 2.8% from the 2024 CF of $33.2875. The change to the PFS conversion factor incorporates the 0.00 percent overall update adjustment factor required by statute, a relatively small estimated positive 0.05% budget neutrality adjustment necessary to account for changes in work relative value units (RVUs) for some services, and the expiration of the temporary 2.93% increase in payment for services furnished from March 9, 2024 through December 31, 2024, as provided in the CAA, 2024. The CFs will affect physician payments in several ways:

• Unless Congressional action is taken, clinicians identified as qualified participants in an Advanced Alternative Payment Model will receive an annual 0.75% update, and all other clinicians will receive a 0.25% annual update along with an additional rate adjustment for relative performance in the Merit-based Incentive Payment System (MIPS).
• This negative adjustment also results from a statutorily mandated budget neutrality adjustment to account for changes in work Relative Value Units (RVUs). This means spending in one year needs to be balanced by reductions and CMS cannot increase or decrease expenditures by more than $20 million without triggering automatic budget neutrality adjustments.

Specialty Impact on Anesthesia and Pain Medicine

Actual payment rates are impacted by a range of proposed policy changes related to physician work, practice expense, and malpractice RVUs. CMS estimated these changes in Table 128 in the proposed rule. Impact by practice will vary based on service mix. Specialty impacts ranged from -2% for Vascular Surgery and Diagnostic Testing Facility, to +4% for Clinical Social Worker. The table indicates that the impact of policies in the proposed rule will have on anesthesiology and interventional pain management. 

Note, changes to the CF are not reflected in the impact table. The impact numbers account for any changes in spending that result from finalized policies that are subject to the statutory budget neutrality requirement. They are aggregate estimated PFS allowed charges summed across all services furnished by physicians within a specialty to arrive at the total allowed charges for the specialty and compared to the same summed total from the previous calendar year. Therefore, they are averages and may not necessarily represent what is happening to the particular services furnished by a single anesthesiologist within any given specialty. The figures below are CMS estimates.

*Note: Combined Impact may not equal the sum of work, PE and malpractice due to rounding. 
Source: Table 128, CY 2025 PFS proposed rule, display copy

Pain Medicine Code Updates

We are happy that CMS accepted the RUC recommendation for the newly created Fascial Plane Block codes. ASA requested new CPT codes in September 2023. ASA surveyed its members in the fall 2023 to develop value recommendations to these codes. The recommendations were presented at the January RUC meeting.

Starting January 1, 2025, pain medicine physicians will be able to get paid by Medicare for providing thoracic (6XX07 – 6XX10) and lower extremity (6XX11 – 6XX12) fascial plane block services reported with these new Category I CPT codes. These new thoracic and lower extremity fascial plane block services expand on this existing transversus abdominis plane (TAP) block code family in CPT (64486 – 64489). For CY 2025, CMS has proposed the following work RVUs for the fascial plane block codes, which are the same as the RUC recommended value. The table below reflects CMS’s proposed work RVUs for the fascial plane block codes.  

Telemedicine Evaluation and Management (E/M) CPT Code Updates

During its February 2023 meeting, the CPT® Editorial Panel approved of a request to establish 16 new Category I E/M telemedicine codes for both new and established patients using audio-video or audio only technology. The Panel also approved one new Category I virtual check in code. The new codes were requested by the AMA’s joint CPT/RUC Telemedicine Office Visits Workgroup, which was established in 2022 to assess available data and determine appropriate next steps for accurate coding and valuation for E/M services performed via audio-visual (AV) and audio-only (AO) modalities. The new telemedicine E/M codes will be effective in CPT beginning January 1, 2025.

When the CPT® Editorial Panel approves the creation of a Category I code, the relevant medical specialty societies survey the physician work and practice expense of the procedure(s) and present their data and recommendations to the AMA Relative-value Update Committee (RUC). The RUC reviewed survey results, including those provided by the ASA, for the new telemedicine E/M codes at its April and September 2023 RUC meetings. 

CMS is proposing to pay for the new virtual check-in code (9X091), and to accept the RUC-recommended work RVU of 0.20. CMS notes that 9X091 would be considered a communication technology-based service that is not subject to the Medicare telehealth services requirements. 

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ASA is committed to advocating for changes to the broken Medicare payment system and ensure that anesthesiologists and pain medicine physicians are paid fairly. ASA has supported an inflation adjustment to Medicare payments to allow for the compensation of our physicians and other clinicians to match rising cost of living across the country. ASA has supported Congressional legislation - H.R. 2474, the Strengthening Medicare for Patients and Providers Act—which would achieve this change.  ASA has also supported Congress and policymakers re-evaluating the budget neutrality clauses of the PFS that greatly restrict payment and cause continued decreases in CFs. ASA looks forward to advocating our position before Congress and in working with CMS and other government stakeholders on proposed solutions.

Please contact ppm@asahq.org with any questions related to the Medicare Physician Fee Schedule.

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Quality Payment Program Provisions:

CMS also released its 2025 Quality Payment Program (QPP) proposals. The proposed rule provides details on how CMS intends for eligible clinicians and groups to participate in the Merit-based Incentive Payment System (MIPS), Alternative Payment Models and other features of the QPP during the 2025 performance year.

For the 2025 reporting year:

• CMS is proposing to maintain the performance threshold at 75 points for CY 2025. Scoring above 75 points would allow an individual or group a payment bonus while scoring below 75 points would result in a payment penalty in 2027.
• By law, the weights of the different MIPS requirements will not change: the quality performance category will be weighted at 30% and the cost performance category will be weighted by 30%. Promoting interoperability and Improvement Activities performance categories will maintain their respective 25% and 15% weights.
• CMS did not make any changes to the anesthesiology measure set.
• CMS will maintain the data completeness threshold for the MIPS Quality Performance Category at 75% for the 2025 through 2028 performance years. A change from previous proposed rules that stated the data completeness threshold would increase to 80% in 2027.
• CMS is proposing to eliminate the 7-point scoring cap on topped out measures and have retained previously topped out measures to ensure there are applicable measures to report.

Anesthesiologists will continue to have the opportunity to report the Anesthesiology MIPS Value Pathway in 2025. MIPS Value Pathways (MVP), CMS believes, will alleviate some of the reporting burdens that anesthesiologists and other physicians encounter in the MIPS program. For 2025, CMS has proposed the same set of measures within the MVP.

CMS is proposing the removal of two Improvement Activities from the MVP:

• IA_CC_2: Implementation of improvements that contribute to more timely communication of test results
• IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

CMS also issued an RFI related to an ambulatory surgical care MVP.

For more information on the Quality Payment Program, please contact the ASA Department of Quality and Regulatory Affairs (QRA) at qra@asahq.org. 

ASA leaders and staff will review the rule and submit comments by the deadline. Unless otherwise noted, finalized provisions will become effective on January 1, 2025.

For more information:

• Proposed Rule text
• CMS Press Release
• CMS Fact Sheet on the Medicare Shared Savings Program (MSSP) 
• CMS Fact Sheet on the Quality Payment Program