Medicare B Calendar Year 2025 proposed rule summary

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released their proposed Calendar Year (CY) 2025 Medicare Physician Fee Schedule (MPFS) Rule and Fact Sheet. These proposed payment policies offer ongoing challenges in Medicare Part B reimbursement but also provide new opportunities that, if finalized, will positively impact the delivery of occupational therapy services beginning in January 2025. These opportunities were the result of extensive advocacy by AOTA and other therapy groups. Many of the key proposed policies important to OT practitioners (OTPs) are outlined below.

Conversion Factor

The conversion factor (CF) is the multiplier Medicare assigns to determine the allowed dollar amount for each service Medicare reimburses under the Physician Fee Schedule. The CF is adjusted yearly to maintain budget neutrality within the fee-for-service system.

• CMS is proposing a CF of 32.3562 for CY 2025

The proposed CF is a decrease from last year, primarily due to the expiration of the Congressionally mandated temporary increase for CY 2024 that went into effect last March. In combination with other scheduled cuts this year, this decrease in CF could result in a significant, almost 3% cut to therapy service reimbursement again this year.

AOTA recognizes the impact that this unstable reimbursement cycle with ongoing cuts has on the workforce and reimbursement challenges we already face. Under the MPFS system, OT and other rehabilitative healthcare professions have received some of the most significant cuts of any health providers as a result of arbitrary rules governing the Medicare Physician Fee Schedule, such as the Multiple Procedure Payment Reduction (MPPR), lack of inflationary updates, and budget neutrality requirements. Each year, CMS is required to remain budget neutral, forcing reductions in the conversion fact, and each year, Congress must step in to mitigate those reductions. AOTA is working collaboratively with the American Physical Therapy Association (APTA), the American Speech-Language-Hearing Association (ASHA), and several key stakeholder groups to effect more lasting change. Last year, AOTA, APTA, ASHA, and the APTA Private Practice section developed a set of policy principles that Congress must adopt to address the unique challenges therapy providers face under the Fee Schedule. These principles are being used to drive legislation that would reform the Medicare Part B payment system by addressing several policies harmful to therapy services.

Telehealth

OT Practitioners as Telehealth Providers

The temporary flexibility that allows OTPs and other therapy practitioners to be telehealth providers expires on December 31, 2024. As a result, CMS has not included language in this proposed rule that would allow therapy practitioners to bill for telehealth services beyond the end of this year. This is because CMS does not have the statutory control to add OTPs to the list of approved telehealth providers—only an act of Congress can do that. Without an extension of the current flexibilities from Congress, access to OT services may be drastically reduced beginning January 1.

AOTA is working tirelessly with Congress in support of the Expanded Telehealth Access Act and other legislation that would make telehealth a permanent part of OT services under Medicare. More immediately, the Preserving Telehealth, Hospital, and Ambulance Access Act (H.R. 8261), which passed the House Ways and Means Committee this past May, would extend current telehealth flexibilities through the end of 2026, giving Congress more time to make OTPs permanent telehealth providers. However, this policy must still be approved by the House Energy and Commerce Committee, the full House of Representatives, and the Senate before it can be enacted. To keep telehealth access available to OTPs, write your member of Congress to support AOTA’s legislation here.

Updates to Medicare Telehealth Services List

Each year, CMS reviews and updates the list of current procedural terminology (CPT) codes available for delivery via telehealth on a permanent or provisional basis. Requests to change the status of current codes or to add new codes to the Medicare Telehealth Services List are due each February. This year, AOTA requested several CPT codes already on the list on a provisional basis be transitioned to the permanent list. CMS responded to this request in the proposed rule, indicating that they do not intend to make any status changes to currently listed codes for this rulemaking cycle but will do a more extensive review of all telehealth in the future. As a result, while current telehealth codes used by OTPs will not be permanent, these codes will remain on the telehealth list for CY 2025.

AOTA also advocated for the inclusion of CPT codes for Caregiver Training Services (CTS). AOTA argued that these services can effectively and equitably be delivered using real-time audio/visual technology, and inclusion in the telehealth list would enable OTPs to reach caregivers who are geographically remote. We pointed out that adding these codes to the telehealth list would also enable OTPs to see inside the client’s home to provide more specific recommendations and training to the caregiver.

• In this proposed rule, CMS agreed with AOTA’s recommendations and announced plans to add CPT codes 97550, 97551, and 97552 to the Medicare Telehealth Services List with provisional, temporary status until peer-reviewed studies supporting these codes’ ability to be furnished remotely can be provided in support of permanent coverage.

AOTA will continue to advocate for the permanent inclusion of OT codes on the Medicare Telehealth Services List to ensure uninterrupted access to OT telehealth services in the future.

Code Valuation Updates

In last year’s final MPFS rule, CMS referred 19 therapy codes back to the American Medical Association (AMA) RVS Update (RUC) Practice Expense (PE) subcommittee to review potential errors that may have occurred in calculating clinical labor inputs for the practice expense (PE) portion of these codes’ values which create a “double payment cut” when the Multiple Procedure Payment Reduction (MPPR) is applied.

AOTA and APTA member experts presented these concerns to the AMA RUC PE Subcommittee to request the revaluation of clinical labor without the duplicative cut included. Each time a code is reviewed, however, all portions of practice expense are opened for inspection. While this review was triggered by concerns in clinical labor inputs, the PE subcommittee also reviewed the supplies and equipment time that make up the rest of the practice expense value to determine if adjustments were needed in those areas. Following this intensive review, final recommendations to CMS resulted in reductions in practice expense for 3 codes but increased practice expense values in 16 of the 19 reviewed codes. In this proposed rule, CMS proposes to adopt the practice expense values recommended by the AMA.

Table 12 in the proposed rule identifies the impact acceptance of the AMA recommendations would have on these 19 codes. Because code valuation is complicated, we do not yet know the impact of these changes on overall code reimbursement.

Advocacy in this area is not over. AOTA will continue to review our code set for opportunities to restructure or revalue codes to impact reimbursement positively.

OTA Supervision in Private Practice

The CMS requirement for direct supervision of occupational therapy assistants (OTAs) in private practice settings has been an ongoing source of frustration and payment inequity for private practice owners and practitioners. In every other Medicare setting, general supervision of OTAs has been allowed. In private practice, however, a 20-year-old Medicare policy requires direct supervision of OTAs—meaning that an OT must be onsite when the OTA works with an OT client. This has led to some private practices hesitating to employ OTAs, given the challenges of staffing two employees for one service and coordinating schedules to meet supervision requirements. Flexibilities resulting from the COVID-19 pandemic have allowed for this direct supervision requirement to be met when the OT is “immediately available” via real-time audio/video (A/V) technology; however, this flexibility is temporary. AOTA has been aggressively advocating over the last several years, both in Congress and with CMS, to remove this requirement and allow for a standardized general supervision policy across Medicare settings.

• In a major win for OT, CMS has announced its intent to allow general supervision of OTAs and PTAs when furnishing outpatient therapy services in private practice under the supervision of Medicare-enrolled OTs and PTs, respectively

AOTA is excited to see their advocacy work realized. This proposed policy could significantly impact access to OT services, especially in rural and underserved areas.

Caregiver Training Services

In the CY 2024 MPFS final rule, CMS approved payment for three new CPT codes that capture Caregiver Training Services (CTS) provided to informal caregivers without the patient present. Reimbursement of these services has been instrumental in ensuring that the informal caregivers of some of the most medically fragile Medicare beneficiaries receive the functional skills training they need to safely and effectively carry out a therapy plan of care. In this year’s proposed rule, CMS provides additional clarity around delivering those services and offers new opportunities to address direct care training needs.

Consent clarified

In last year’s final rule, CMS stipulated that the treating practitioner must obtain the patient’s (or representative’s) consent for the caregiver to receive the CTS and that the consent for one or more specific caregivers to receive CTS must be documented in the patient’s medical record. Citing ongoing interested parties’ questions about what that consent should look like, CMS is clarifying that the consent for CTS can be provided verbally by the patient (or representative).

New coding guidance for assessment of caregiver knowledge

In response to interested parties’ requests for assessment of a caregiver’s knowledge to be included in caregiver training, CMS has clarified that “assessing the caregiver’s skills and knowledge for the purposes of caregiver training services could be included in the service described by CPT code 96161 (Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument) to determine if caregiver training services are needed.”

• Because the assessment may be furnished outside the patient’s presence, the treating practitioner must obtain the patient’s (or representative’s) consent for the caregiver to receive the assessment.
• The definition of “caregiver” as an informal, unpaid lay person used for CTS would be the same for the caregiver-focused health risk assessment.

Direct Care Caregiver Training Services

CMS additionally proposes to establish new coding and payment for caregiver training (without the patient present) for caregiver training for direct care services. The training would focus on specific clinical skills aimed at the caregiver, effectuating hands-on treatment, reducing complications, and monitoring the patient. Example topics include but are not limited to:

• How to properly change wound dressings to promote healing and prevent infection
• Techniques to prevent decubitus ulcer formation
• Infection control
• Other medical treatment scenarios where assistance by the caregiver is necessary to ensure a successful treatment outcome for the patient--for example, when the patient cannot follow through with the treatment plan for themselves

These services would not be billable for patients under a home health plan of care, receiving at-home therapy, or receiving DME services for involved medical equipment and supplies.

Three new HCPCS codes are proposed:

• GCTD1 for initial 30 minutes of caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (without the patient present)
• GCTD2 for each additional 15 minutes of caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (without the patient present), (List separately in addition to code for primary service) (Use GCTD2 in conjunction with GCTD1)
• GCTD3 for group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (without the patient present), face-to-face with multiple sets of caregivers, untimed

CMS identifies that the definition of caregiver for these new services would reflect the current definition for other CTS codes so that training would be targeted at informal, unpaid caregivers.

CMS is seeking comments about potential service overlaps and examples of direct care services to receive caregiver training to inform the final policy. AOTA continues to be concerned about the care gaps that may result from the definitions of caregivers as informal and unpaid laypersons. Some laypersons receive small state stipends or private payments from a family member of the client to provide caregiving but lack formal training in providing that care. We will continue to advocate with CMS to consider a broader definition of “caregiver” for CTS to include these informal, paid caregivers in the future.

Reducing the burden associated with physician's signature on the plan of care

Current regulations stipulate that payment for Medicare therapy services may be made for outpatient therapy services only if a physician certifies that: (a) the services are or were required because the patient needs or needed therapy services; (b) a plan for furnishing such services was established by a physician or qualified therapist providing such services, and is periodically reviewed by the physician; and (c) the services are or were furnished while the individual was under the care of a physician.

To meet these requirements, Medicare requires the plan of care (POC) to be signed by the physician within 30 days of completion. To remain in compliance and ensure payment for their services, therapy practitioners often undergo exhaustive efforts to obtain the physician's signature, repeatedly calling, faxing, emailing, or even hand-delivering the POC to the physician in their office. While delayed certification is allowed under the regulation, it also requires the physician's signature, leaving therapy practitioners accountable for the action or inaction of physicians who may be overwhelmed with caseloads and paperwork. Over the past two years, AOTA, APTA, and ASHA have met with CMS to address this administrative burden, and CMS has finally responded to our concerns. In this proposed rule, CMS offers some relief to this high administrative burden associated with obtaining the physician's signature on plans of care.

• CMS proposes that where a signed and dated order/referral from a physician is present in the record, documentation of such order/referral in the patient’s medical record, along with further evidence in the medical record that the therapy POC was transmitted/submitted to the ordering/referring physician would be sufficient to demonstrate the physician’s certification of that POC.

Note that this proposal would cover only the therapy POC—if the POC requires recertification, a physician’s signature on the recertification document will still be required. The proposed policy would be an exception to the physician signature requirement for purposes of an initial certification only and only in cases where a signed and dated order/referral is on file, and the therapist has documented evidence that the plan of treatment has been delivered to the physician within 30 days of completion of the initial evaluation. This documentation could be similar to documentation already required to establish a delayed certification. It could be fax cover sheets, emails, or other records documenting the attempts to submit the initial POC for signature by the physician.

Merit-based Incentive Payment System (MIPS)

OTPs who meet certain participation criteria can participate in the Merit-based Incentive Payment System (MIPS). Each year, CMS reviews and revises its policies for the MIPS program. This year, there are several Requests for Information (RFIs) on the future of MIPS, MIPS Value Pathways (MVPs), and improving adoption of MIPS for MIPS-eligible clinicians that we plan to respond to in our comments to advocate for improved OT inclusion and access to measures for both traditional MIPS and for consideration in newly developed MVPs.

Several changes impact OT, including changes to the following Quality Measures:

• Documentation of Current Medications in the Medical Record
• Falls: Plan of Care
• Elder Maltreatment Screen and Follow-Up Plan
• Functional Outcome Assessment
• Dementia: Cognitive Assessment
• Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
• Dementia: Education and Support of Caregivers for Patients with Dementia
• Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease
• Connection to Community Service Provider
• Gains in Patient Activation Measure (PAM®) Scores at 12 Month

These changes primarily update measure numerators, defining clients who trigger or update measure denominators to add OT coding. Significant updates to the PAM measure relate to the timing of the survey, minimum performance thresholds, qualifying number of visits, and removing patients who died prior to the survey window.

The AOTA review of the proposed MIPS policies in this rule is ongoing; updates will be provided as we further analyze the impact of other proposed policy changes.

Make your voice heard

Each year, CMS publishes its proposed policies to allow the public to provide feedback before finalizing policies for the following year. AOTA encourages members to learn more about these proposed changes and to comment to CMS on the policies that will affect their OT practice. This is our profession’s opportunity to make our voices heard on policies that will significantly impact OT reimbursement and Medicare Part B beneficiary access to OT services in the coming year.

Members can also share feedback by emailing regulatory@aota.org.