CY 2025 Medicare Physician Fee Schedule Final Rule Summary
On November 1, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for Calendar Year (CY) 2025 (CMS-1807-F). The rule updates payment policies and rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP). The rule in its entirety and the addenda, including Addendum B, which lists the proposed RVUs for each CPT® code can be found here.
CMS finalized several significant policy changes, including creating a new code to address the global surgical package policy, requiring use of a modifier for 90-day global surgeries, redefining telehealth services to include audio-only services, and declining to accept and pay for the new 16 of the 17 telemedicine E/M codes. The following summarizes the major policies of the final rule. Note that the page numbers listed in this document refer to the display copy of the final rule.
Regulatory Impact Analysis
Highlight: Conversion factor set for a decrease yet again for CY 2025
Conversion Factor for 2025
The conversion factor for 2025 is set to decrease by approximately 2.83% from $33.2875 to $32.3464. The cut is primarily driven by the expiration of the conversion factor increase that Congress passed in March, coupled with a 0% baseline update.
Changes in Relative Value Unit Specialty Level Impact – p. 2,326
The impact of the final rule’s policies on group practices and individual physicians varies based on practice type, the mix of services provided to patients, and the patient mix. Table 110 of the rule, (Appendix A of this summary) estimates the specialty level impacts of the policies finalized for 2025 and includes impacts of rate-setting changes and changes to RVUs within the budget neutral system. Table 1 below highlights estimated specialty level impacts and includes some of the specialties with the greatest impact, both positive and negative for comparison. Note that the impact table values do not reflect the decrease in the conversion factor for 2025.
Table 1: CY 2025 Estimated Impact Total Allowed Charges by Specialty
| Specialty | Medicare Allowed Charges (millions) | Work RVU Impact | PE RVU Impact | MP RVU Impact | Overall Impact |
| Clinical Social Worker | $894 | 3% | 1% | 0% | 4% |
| Endocrinology | $517 | 0% | 0% | 0% | 1% |
| Internal Medicine | $9,491 | 0% | 0% | 0% | 0% |
| Rheumatology | $520 | 0% | -1% | 0% | 0% |
| Infectious Diseases | $555 | 0% | 0% | 0% | 0% |
| Hematology/Oncology | $1,579 | 0% | -1% | 0% | -1% |
| Allergy/Immunology | $218 | 0% | -1% | 0% | -1% |
| Interventional Radiology | $445 | 0% | -2% | 0% | -2% |
Determination of Practice Expense RVUs – p. 31
Highlight: No change in the MEI methodology while CMS waits for updated practice expense data from the AMA.
The agency finalized its policy not to adjust RVUs using MEI methodology. The agency reiterated that it would continue to wait for the results of the American Medical Association’s Physician Practice Information Survey before making any significant changes to the data inputs and calculation of the practice expense RVUs.
CY 2025 Clinical Labor Pricing Update – p. 61
Highlight: CMS finalized pricing for clinical labor types.
The agency did not receive new wage data during the comment period or any other information for use in its calculation of clinical labor pricing. Therefore, the data finalized in 2024 will be used for clinical labor pricing again in 2025. Table 8 of the final rule lists the clinical labor types and their price per minute for 2025.
Development of Strategies for Updates to Practice Expense Data Collection and Methodology – p. 71
Highlight: CMS provides no additional information on how it will update practice expense inputs.
The agency said very little in the final rule regarding how they intend to update the practice expense portion of the MPFS, and thanked commenters for their input, while noting that CMS will consider comments in future rulemaking. The agency requested information on many topics including alternative data sources to AMA Physician Information Survey, timing of recurring updates to the practice expense inputs, and the use of four-year phase-in policy when new data is implemented.
Payment for Medicare Telehealth Services under Section 1834(m) of the Act – p. 106
Highlight: CMS adds audio-only communication technology to the definition of a telehealth service.
Requests to Add Services to the Medicare Telehealth Services List for CY 2025
CMS plans to complete a comprehensive analysis in future rulemaking of all the services on the Medicare Telehealth Services List provisionally before determining which codes should be made permanent. The process and decision-making parameters that the agency uses to make determinations as to whether a code(s) may be placed on the telehealth service list is found on page 108 of the final rule.
Care Management – p. 122
CMS received a request to permanently add General Behavioral Health Integration (CPT code 99484) and Principal Care Management (CPT codes 99424-99427) to the Medicare Telehealth Services List. The agency does not consider these to be Medicare telehealth services and therefore is not adding these services to the Medicare Telehealth Services List. As noted in the rule the agency states, “We do not consider these services to be Medicare telehealth services because they are not inherently face-to-face services, and the patient need not be present for the services to be furnished in its entirety.”
Frequency Limitations of Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations
Prior to the COVID pandemic, there were frequency limitations (i.e., the number of times a provider may bill for a service during a given time frame) for services associated with subsequent inpatient visits (CPT codes 99231, 99232, and 99233), subsequent nursing facility visits (CPT codes 99307, 99308, 99309, and 99310), and critical care consultation services (HCPCS G codes, G0508 and G0509). However, during the pandemic, CMS lifted the frequency restrictions to allow greater access to care.
The agency finalized the proposal to continue suspension of the telehealth frequency limits on subsequent inpatient and nursing facility visits and critical care consultations for CY 2025. This will give the agency to gather an additional year of data to determine how practice patterns are evolving and what changes, if any, should be made to this policy permanently.
Audio-only Communication Technology to Meet the Definition of “Telecommunications Systems”
CMS permanently revised the definition of an interactive telecommunications system to include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site physician is technically capable of using an audio/video system, but the patient is not capable of, or does not consent to, the use of video technology. The agency notes that providers should continue to use their clinical judgment to decide if audio-only technology is sufficient to provide a telehealth service.
However, the agency recognizes that lack of access to broadband may make video calls impractical, or that patients may prefer to engage with their provider in their homes using audio-only technology. For claims for audio-only services, providers must use CPT modifier 93 to verify that all conditions have been met. No additional documentation except for the appropriate modifier is needed.
Distant Site Requirements
For CY 2025, CMS finalized the proposal to continue to allow a distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. The agency will consider proposals to better protect the safety and privacy of providers.
Direct Supervision via Use of Two-way Audio/Video Communications Technology
CMS finalized the proposal to continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications systems through December 31, 2025. The agency permanently adopted the definition of direct supervision permitting virtual presence for services that are considered lower risk, such as services that do not ordinarily require the presence of the billing practitioner, do not require as much direction by the billing practitioner as other services, and are not typically performed by the supervising practitioner.
Teaching Physician Billing for Services Involving Residents with Virtual Presence
CMS will continue the current policy, which allows teaching physicians to have a virtual presence when billing for services involving residents in teaching settings only when the service is furnished virtually (i.e., the patient, resident and teaching physician are all in separate locations), through December 31, 2025. The teaching physician’s virtual presence requires real-time observation and excludes audio-only technology.
Telehealth Originating Site Facility Fee Payment Amount Update
For CY 2025, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) will be $31.01.
Telehealth Place of Service Code
The agency noted that claims for telehealth services billed with POS 10 (telehealth provided in patient’s home) will continue to be paid at the non-facility PFS rate for CY 2025 and beyond.
Valuation of Specific Codes
Therapeutic Apheresis and Photopheresis (CPT Codes 36514, 36516, 36522) – p. 203
CPT codes 36514 (Therapeutic apheresis; for plasma pheresis), 36516 (Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion), and 36522 (Photopheresis, extracorporeal) were identified as potentially misvalued in the 2024 MPFS final rule. The misvaluation was determined to result from the inclusion of a lower paying clinical labor type RN/LPN.
At the January 2024 AMA RUC meeting, it was determined that given there is no clinical staff code for apheresis nurse specialist, that the best approximation for an apheresis nurse specialist is an oncology nurse. CMS finalized the use of an oncology nurse as the clinical labor type for services associated with CPT codes 36514, 36516, 36522.
CAR T-cell Therapy Services (CPT Codes 38225, 38226, 38227, and 38228) – p. 201
At the September 2023 AMA CPT Editorial Meeting, four Category I CPT codes used to report services associated with the process of harvesting (38225), preparation for transport (38226), receipt and preparation (38227), and administering CAR T-cell therapies (38228) were created. The Category I codes subsequently underwent an AMA RUC survey to determine the relative values for each code. CMS finalized the RUC proposed work RVUs without modification, for all four services. However, while the agency accepted, and will publish the work RVUs in the RVU file, they will not make separate payment for codes 38225, 38226, and 38227. These three services will have a payment status indicator of B – bundled code. Per the CMS definition of a bundled service, if these services are covered, payment for them is subsumed in the payment for the services to which they are bundled. CPT code 38228 for the cell administration will be paid separately.
Table 2: Work RVUs for CAR T-cell Services
| CPT Code | Descriptor | Final Work RVU |
| 38225 | Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day | 1.94 |
| 38226 | Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) | 0.79 |
| 38227 | Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration | 0.80 |
| 38228 | Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration | 3.00 |
In the proposed rule, the agency proposed the RUC-recommended practice expense (PE) value for code 38228, which is used to report the administration of CAR T-cell therapy. However, for services associated with 38225, 38226, and 38227, the AMA RUC recommended Medicare contractor pricing for the non-facility PE RVUs, but the agency will not contractor price a single component, i.e., the PE portion of the valuation. Therefore, effective January 1, 2025, only CPT code 38228 will have the RUC-recommended PE value as this is the only service in the family that will be payable separately.
Telemedicine Evaluation and Management (E/M) Services (CPT codes 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, and 98016) – p. 234
As a part of its work in a nearly complete overhaul of the E/M section of the CPT code book, the CPT Editorial Panel created, and the RUC subsequently valued 17 new codes to describe services for the provision of telemedicine E/M services. CMS finalized policy stating that there is no programmatic need to recognize and provide payment for 16 of the 17 newly established telemedicine E/M codes, and therefore assigned 16 of the codes a status indicator of “I” which indicates there is a more specific code that should be used in the Medicare program, in this instance the existing office E/M codes. Instead, the agency states that providers should continue to use the existing office/outpatient E/M CPT codes, which are on the telehealth services list. Providers should use appropriate place of service codes to identify the location of the Medicare beneficiary, and use appropriate modifiers as required.
However, CMS finalized payment for CPT code 98016 (Brief communication technology-based service (eg, virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion). CMS will delete HCPCS code G2012, used to report similar services, and instead beginning January 1, 2025, providers should use the new CPT code to report a virtual check-in. Code 98016 will have a work RVU of 0.30, and the RUC recommended direct PE inputs have been finalized by CMS.
Non-Chemotherapy Administration – p. 298
Highlight: CPT guidelines and code definitions will be incorporated into Medicare operating manual to clarify coding for the provision of non-chemotherapeutic agents.
CMS finalized policy to update the Medicare Claims Processing Manual, chapter 12, section 30.5, that will modify the coding language to match CPT code definitions for complex non-chemotherapy infusion code series stating that the administration for certain of drugs and biologics may be considered complex and may be appropriately reported using the chemotherapy administration CPT codes 96401-96549. CMS believes that Medicare Administrative Contractors will now have the information needed to process claims appropriately for non-chemotherapy complex drugs and biologics.
In the 2024 proposed fee schedule rule, CMS requested comment on payment for non-chemotherapeutic complex drug administration services to address concerns that non-chemotherapeutic complex drug administration payment is inadequate due to existing coding and Medicare billing guidelines. Specifically, the agency wanted to know if there were “concerns for down coding or denials for the administration of non-chemotherapeutic infusion drugs.” Commenters, including ASH, suggested the agency follow the coding guidelines and coding construct outlined in the CPT code book, stating that the CPT coding guidelines are sufficient to describe the services associated with the administration of drugs and biologics.
Hospital Inpatient or Observation (I/O) Evaluation and Management (E/M) Add-on for Infectious Diseases (HCPCS code G0545) – p. 194
Highlight: New code for infectious diseases care finalized.
CMS finalized the code descriptor and will make payment for HCPCS code G0545 (Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases specialist, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment. (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, or subsequent).
The new code will “describe the intensity and complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease performed by a physician with specialized training in infectious diseases.” HCPCS code G0545 is an add-on code that if all conditions and documentation guidelines are met, may be appended to claims with hospital inpatient and observation E/M services. The full complement of services encompassed by this code may be found on page 304 of the final rule. The code has been assigned a work RVU of 0.89.
Request for Information for Services Addressing Health-Related Social Needs (Community Health Integration (G0019, G0022), Principal Illness Navigation (G0023, G0024), Principal Illness Navigation-Peer Support (G0140, G0146), and Social Determinants of Health Risk Assessment (G0136) – p. 213
Highlight: CMS thanks commenters for additional information but did not finalize new policy.
During last year’s rule making cycle, the agency proposed and finalized payment under the MPFS for services that address the health-related social needs of Medicare beneficiaries. These services included community health integration, principal illness navigation, principal illness navigation-peer support, and the provision of a social determinants of health risk assessment. The new services were created as part of the Biden administration’s plan to increase access to care in a fair and equitable manner. The agency requested additional information on ways to improve these services, address any care gaps that may not be covered by the new codes, and possibly create additional codes within the scope of this policy. The agency simply thanked commenters and stated that comments will be taken into consideration if future rulemaking.
Proposals on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Services – p. 616
Highlight: CMS again denies coverage for dental services related to SCD and hemophilia.
Consideration of Dental Services that may be Inextricably Linked to Other Covered Services
CMS partnered with the Agency for Health Research and Quality (AHRQ) to review the relationship between dental services and other specific covered services. AHRQ conducted rapid response reports to analyze which payments can be made under Parts A & B for certain dental services that are inextricably linked to other covered services.
To gather information on the provision of dental services, the agency partnered with AHRQ to review available clinical evidence on the relationship between dental services and specific covered sickle cell disease (SCD) or hemophilia medical services. The link to the two rapid response reports can be found here and here. In the case of both SCD and hemophilia, the review found an absence of primary evidence that informed the potential effect of dental care on health outcomes for the patient populations. For SCD, the report highlights that despite hydroxyurea’s long-term use as a treatment, there is uncertainty about whether dental care before, during, or after treatment of SCD with hydroxyurea (and other lesser prescribed treatments) influences clinical outcomes in patients. Studies showed that preventive dental care is important for people with SCD but did not study the impact of dental care on the improvement of SCD. For hemophilia, the report noted that research focuses on the importance of dental care during clotting factor replacement therapy to reduce bleeding complications but did not show the impact of dental services on patient outcomes. The current evidence base does not appear to support the idea that dental services may be inextricably linked to covered services for sickle cell disease and hemophilia.
CMS summarized the comments received on the consideration of dental services that may be inextricably linked to covered services for the treatment of SCD and hemophilia. Despite the comments received, the agency did not find support for finding that dental services are inextricably linked to a covered medical service for SCD or that the standard of SCD care would be compromised without dental services or that the standard of SCD care would require dental services to be performed in conjunction with treatments for SCD; the same conclusions were reached for hemophilia. The agency remains committed to seek clinical evidence demonstrating the inextricable link between dental services and other covered services for SCD and hemophilia.
Submissions through Public Submission Process
Submissions for the CY 2026 PFS rulemaking for additional clinical scenarios for which dental services are inextricably linked to other covered services should be received by February 10, 2025 and may be submitted to MedicarePhysicianFeeSchedule@cms.hhs.gov.
Implementation of Payment for Dental Services Inextricably Linked to Other Specific Covered Services
Effective July 1, 2025, the KX modifier is required for claims submissions for dental services inextricably linked to covered medical services on the dental claim format 837D, the professional claim form 837P and the institutional claim form 837I. Practitioners who bill for dental payment must include the KX modifier to indicate that they believe that the dental service meets the established payment criteria; that the practitioner has included appropriate documentation in the medical record to support or justify the medical necessity of the service or item, and that the coordination of care between the medical and dental practitioners has occurred.
Effective July 1, 2025, CMS requires the reporting of a diagnosis code on the dental claim form for physician’s services inextricably linked to covered medical services. The agency delayed implementation for these two provisions to allow sufficient time for comprehensive testing, reporting, and educational materials for healthcare providers, vendors, and payors.
CMS finalized that the GY modifier may be used on professional, dental, and institutional claim forms in instances where a Medicare claim denial is sought for purposes of submission to third party payers or where the dental service does not fit within a Medicare benefit category and is statutorily excluded from coverage.
CMS received comments on the need for the agency to educate providers on billing practices and how dental policies apply to different programs. The agency will continue to seek ways to better educate healthcare providers on billing practices and supplemental dental coverage. An FAQ is available here: Medicare Dental Coverage.
Appendix A: Specialty Level Impact Table
Table 110: CY 2025 PFS Estimated Impact on Total Allowed Charges by Specialty
Appendix B: Payment Rates for Medicare Physician Services
2025 Medicare Physician Fee Schedule Final Rule
ASH Comment Comparison
| Submitted Comments | Final Rule Provision |
| Commented on the lack of updates to conversion factor, recognizing that CMS cannot update the conversion factor without Congressional intervention. | CMS did not address any specific comments in the final rule but was appreciative of comments from all stakeholders. |
| Supported removing frequency limitations for E/M services when provided via telemedicine for CPT and HCPCS codes: subsequent inpatient visits (99231, 99232, and 99233), subsequent nursing facility visits (CPT codes 99307, 99308, 99309, and 99310), and critical care consultation services (HCPCS G codes, G0508 and G0509). | CMS finalized policy to pause frequency limitations but will not remove the frequency limitations permanently. The agency will continue to study the effect of this policy on the care of Medicare beneficiaries. |
| Supported inclusion of the term audio-only into the definition of a telecommunications system. | Policy was finalized. |
| For CPT codes 36514, 36516, and 36522 supported using an oncology nurse as the clinical labor type for these services. | Policy was finalized. |
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- Supported the work RVU and practice expense (PE) for CPT code 38228 used to report CAR T-cell therapy administration. - Supported work RVUs for 38225, 38226, and 38227 (codes used to report the services to collect, prepare, and transport CAR T-cells. - Recommended contractor pricing for PE inputs for codes 38225, 38226, and 38227. |
CMS finalized the PE and work values for 38228. CMS will bundle the other services (38225, 38226, and 38227). The codes are assigned a payment status indicator of B = bundled service in the RVU file, which means there will be no separate payment. |
| Supported CMS policy to not pay for the new telemedicine E/M codes and supported the policy to use the current set of E/M codes to describe E/M services provided via telemedicine. | This policy was finalized. However, CMS will make payment for one of the new codes, 98016 (brief communication technology-based service (e.g., virtual check-in), and will delete G2012 which was used to report a similar service. |
| Recommended CMS follow the existing coding guidelines and constructs outlined in the CPT code book for non-chemotherapeutic complex drug administration and supported updating the Medicare Claims Processing Manual (MCPM) to modify the coding language to match the CPT code book. | CMS will update the MCPM to clarify coding guidelines for the administration of non-chemotherapeutic complex drugs. |
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- Recommended that HCPCS code G0545 (E/M services provided by infectious diseases specialists in the hospital setting) not be implemented. - Also recommended the creation of a HCPCS G code (that is not specialty specific) for use with hospital E/M codes, like G2211 which is used with office E/M codes to report complex patient care. |
CMS did not agree. The code will be effective on January 1, 2025. The final rule specifically mentions the ASH comment regarding creation of a nonspecific code, like G2211 for inpatient complex patients, and the ASH comment that CPT codes (if one were created for this service), are not meant to be specialty specific. The agency doubled down and stated, “we reiterate that we would consider using any newly available CPT coding to describe infectious disease services in future rulemaking.” |
| ASH submitted comments thanking the agency for reviewing the request to cover dental services as inextricably linked to other covered services for people with SCD and hemophilia. |
CMS finalized that it will NOT cover dental services for SCD and hemophilia. CMS states “we need to identify specific covered medical services for which there is medical evidence that certain dental services are so integral to their clinical success that they are inextricably linked to the covered service. Based on the information provided, we have not been able to identify such a specific covered medical service for SCD or hemophilia, and thus we are unable to evaluate whether any medical evidence would support an inextricable linkage to certain dental services.” Again, the submitted comments were restated nearly word for in the final rule. We note this to point out that agency staff do indeed read the comments submitted. |