Medicare Issues 2025 Proposed Payment Policies for Outpatient Services

July 17, 2024

The Centers for Medicare & Medicaid Services (CMS) recently proposed changes to the 2025 Medicare Physician Fee Schedule (MPFS)—which establishes payment policies and rates for Part B (outpatient) services—that could negatively impact Medicare payment and access to care. The following information highlights key provisions impacting audiologists and SLPs, what ASHA Advocacy is doing or has done, and what ASHA members can do.

The Top Line

CMS estimates a 2.8% payment cut but it could be as high as 9% because of multiple budget control mechanisms that Congress controls.
Despite extensive ASHA advocacy, CMS opts not to add audiology and speech-language pathology related services to the permanent telehealth services list.
Updates to the therapy plan of care certification requirements could reduce administrative burden for SLPs.
Caregiver training services (CTS) see a policy update that will allow SLPs to obtain a patient’s verbal consent.
CMS provides no updates regarding the audiology access (“AB modifier”) provision.

There are two proposed policies that ASHA does not support: payment cuts and not including our services in the permanent telehealth list. We need to use our collective voices to fight against the pending 2.8% reduction to Medicare Part B payments and for securing permanent telehealth authority. Consistent, powerful advocacy is critical through the end of 2024 to ensure CMS is implementing the Medicare benefit so that clinicians are appropriately paid for the services they provide and to avoid jeopardizing patient access to care. Congress must act to prevent further debilitating payment cuts and loss of telehealth privileges in 2025.

Payment Rates

Conversion Factor

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. For 2025, CMS estimates that the CF will be $32.36, representing a 2.8% decrease from the $33.29 CF for 2024. Although CMS included a 0.05% positive budget neutrality adjustment, the proposed decrease in the CF is mostly due to expiration of the temporary 2.93% positive adjustment that Congress implemented to temporarily mitigate significant payment cuts in 2024.

CMS’s regulatory impact analysis (RIA) estimates that audiologists and SLPs will see a cumulative 0% change in payments based on the CF update and policy changes proposed for 2025. However, cumulative payment changes experienced by individual clinicians or practices will vary because actual payment depends on several factors, including the clinician’s location and the specific procedure codes billed.

ASHA is analyzing the proposed adjustments to professional work, practice expense, and liability insurance values for individual procedure codes to determine how the CF will affect national payment rates for audiology and speech-language pathology services.

Additional Payment Cuts

Medicare providers face other cuts known as sequestration (2% reduction) and statutory "Pay-As-You-Go", or PAYGO (4% reduction), due to laws that control federal spending. Although these specific cuts aren’t addressed in the MPFS, they could result in a total cut of almost 9% to overall Medicare payments when added to the CF reduction.

Congress has acted each year by passing legislation that reduced or eliminated some of these additional cuts and will need to do so again for 2025 payments.

Next Steps for ASHA: Annual reductions hurt our members and their patients, which is why we have strongly advocated against Medicare Part B payment cuts since they were first set to occur in 2021. This vicious cycle requires all of us to push against CMS on its proposed changes and lobby Congress to intervene and to stop the payment cuts. Thankfully, Congressional intervention has helped soften the blow of the cuts each year, but it’s not enough. Medicare providers will continue to face payment instability unless Congress acts to reform the Medicare payment system. ASHA is fully committed to continuing advocacy and collaboration with members of Congress, CMS, key decision makers, and allied professional organizations (whose providers are also impacted) to find short- and long-term solutions to address Medicare payment issues, including supporting H.R. 2474, the Strengthening Medicare for Patients and Providers Act.

What You Can Do: ASHA members can take action by urging their members of Congress to fully address the multiple sources of payment reductions, including by cosponsoring H.R. 2474, which would provide an annual inflationary payment update based on the Medicare Economic Index. Ask your colleagues and friends to do the same to support this important legislation.

Take Action to Stop the Cuts

Coding Updates

Although there are no new or revised procedure codes directly related to audiology or speech-language pathology services for 2025, SLPs should be aware of proposed updates to policies around the caregiver training services (CTS) codes.

Caregiver Training

Beginning in 2024, SLPs have been able to report caregiver training services (CTS) without the patient present when provided under an established, individualized, and patient-centered plan of care. The proposed rule includes refinements to the existing CTS policies.

Patient Consent

One criterion for CTS billing requires the SLP to receive consent from the patient (or their representative) to provide caregiver training without the patient present; however, CMS does not dictate the form or manner of obtaining and documenting this consent. The flexibility of this policy is important to ensure clinicians can obtain consent in a manner that reduces administrative burden and maintains access to care for patients. In the proposed rule, CMS includes important and helpful guidance to allow verbal consent from the patient or the patient’s representative. The verbal consent must be documented somewhere in the patient’s medical record, but CMS maintains the flexibility to allow clinicians and facilities to determine their own protocols for obtaining and documenting consent.

Telehealth List

CMS is proposing to add CTS to the authorized telehealth services list for 2025, but on a provisional basis. In 2024, CTS was not an eligible telehealth service. However, given that audiologists and SLPs may not be eligible to continue to provide telehealth services in 2025 without Congressional action, it is unclear how helpful this flexibility will be.

New Caregiver Training G-Codes for Primary Care Services

CMS is proposing a new set of Medicare-specific G-codes for caregiver training without the patient present in direct care strategies and techniques to support care for patients with ongoing conditions or illness and to reduce complications (including but not limited to techniques to prevent decubitus ulcer formation, wound dressing changes, and infection control). These are similar to the existing CTS codes available for SLPs and valued at the same rate. These G-codes are intended to be used in primary care services.

Next Steps for ASHA: ASHA will seek clarification on how the new Medicare specific G-codes for caregiver training may overlap with services described in the CTS codes used by SLPs. We will express support for verbal consent from the patient or patient’s representative.

Telehealth

ASHA Request to Add Services to the Authorized Telehealth List

The structure of the Medicare telehealth benefit is split between Congress and CMS.

Congress	CMS
Determines the clinical specialties who are eligible telehealth providers	Determines which services are covered telehealth benefits

CMS has an established process for reviewing requests from the public to add Current Procedural Terminology (CPT®) codes to the authorized telehealth services list on a permanent basis. This process requires that a letter, outlining the codes being requested for addition to the list along with research and evidence supporting their inclusion, be submitted to the Agency by February 10 of each year. CMS staff review these requests and outlines their determinations in each year’s proposed rule.

ASHA submitted a request [PDF] in February 2024 requesting that CMS permanently add audiology and speech-language pathology CPT codes that have been temporarily authorized telehealth services since March 2021. While audiologists and SLPs may not be authorized telehealth providers in 2025 without Congressional action, ASHA maintains that the development of a robust telehealth benefit is critically important to ensure continuity of care for Medicare beneficiaries by ensuring there is a benefit in place that can be more easily implemented when these clinicians are added.

Unfortunately, CMS stated that it would not add any CPT codes that currently have provisional approval to the authorized telehealth services list in 2025―including audiology and speech-language pathology services―until it has performed a “comprehensive analysis” of these services. This proposal does not align with the formalized approval process developed by CMS. It does not address the merits of the request ASHA submitted earlier this year. Further, CMS fails to define what a “comprehensive analysis” is or what it would entail making it challenging, at best, to respond to this proposal. It also fails to provide a rationale for why a “comprehensive analysis” is required and why its own formalized review criteria are insufficient to make a determination to add these services to the authorized telehealth services list.

Updated Telehealth Policies

CMS will continue to allow clinicians who are providing telehealth services to Medicare beneficiaries from their homes to use their business address on claims to protect their privacy and security. CMS also proposes to permanently allow two-way, real-time audio-only communication technology to qualify as a telehealth service furnished to a beneficiary in their home if the clinician is technically capable of using audio and video equipment that enables two-way, real-time interactive communication, but the patient is not capable of, or does not consent to, the use of video technology. To use this flexibility, clinicians in outpatient settings will be required to report modifier “93” (audio-only synchronous telemedicine service) on the claim to verify that these conditions have been met.

Next Steps for ASHA: We are dissatisfied with CMS’s decision to not include audiology and speech-language pathology services on its proposed list of approved CPT codes, despite our efforts to work within their processes. ASHA is committed to securing permanent authority for audiologists and SLPs to receive payment for services provided via telehealth at parity with payment for in-person services. We will also strongly oppose CMS’s inaction in our comments.

What You Can Do: Visit ASHA’s Take Action site to urge your members of Congress to advocate for permanent telehealth coverage under Medicare.

Take Action for Telehealth Coverage

Updates to the Therapy Plan of Care Requirements

For 2025, CMS is proposing amendments to the certification of the plan of care regulations to reduce the administrative burden for therapists and physician/nonphysician practitioners (NPPs). These changes, if finalized, would provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification. This exception would apply in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation.

CMS is also soliciting comments on the need for a regulation addressing the amount of time during which the physician/NPP who has written an order for therapy services could make changes to the therapist-established treatment plan by contacting the therapist directly.

Next steps for ASHA: ASHA will comment in support of this change because it reduces administrative burden for SLPs and their physician colleagues.

Supervision of Therapy Assistants

For 2025, CMS proposes a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services. At this time speech-language pathology assistants (SLPAs) are not recognized under federal law as qualified providers and, therefore, their services are not covered. Once we secure coverage, we will need to confirm this policy applies equally to SLPAs.

Telesupervision of “Incident To” Services

SLPs, PTs, and OTs are allowed to provide services “incident to” a physician with direct supervision. “Incident to” coverage policies state that the services of the therapist would be billed under the National Provider Identifier (NPI) of the supervising physician. Direct supervision is typically defined as in the office suite and immediately available to help if needed. This definition was relaxed during the COVID-19 public health emergency to allow for telesupervision―supervision via real-time audio and visual interactive telecommunications.

CMS is proposing to allow telesupervision through 2025 for physical and occupational therapy and speech-language pathology services. In addition, it proposes to allow for telesupervision on a permanent basis for any CPT code with a professional and technical component (PC/TC) status indicator of “5” and services described by CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional). CPT codes primarily billed by SLPs do not have a PC/TC status indicator of “5,” which means that unless CMS makes additional changes through rulemaking for 2026, SLPs will not be eligible to be telesupervised after 2025.

However, CMS proposes to add services to the telesupervision list at any time if they meet specified criteria including the services that are inherently lower risk. This includes services that 1) do not ordinarily require the presence of the billing practitioner, 2) do not require direction by the supervising practitioner to the same degree as other services furnished under direct supervision, and 3) are not services typically performed directly by the supervising practitioner.

Next steps for ASHA: ASHA believes speech-language pathology services meet this proposed criteria for permanent telesupervision and will urge CMS to finalize telesupervision on a permanent basis.

Quality Payment Program (QPP)

The QPP transitions Medicare payments away from a volume-based fee-for-service payment to a more value-based system of quality and outcomes-based reimbursement. The program includes Advanced Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS).

Alternative Payment Models (APMs)

Only a small percentage of audiologists and SLPs participate in the APM track. These clinicians typically work for larger health care systems and have the support of finance and administration departments to manage the complexity of such models. CMS proposals in this rule would add new quality measures and reward efforts to improve health equity. They also request information on higher risk/higher reward options. Audiologists and SLPs working for organizations participating in APMs can help their organizations earn incentive payments by engaging in quality improvement efforts.

APMs are designed to improve the patient experience by encouraging collaboration between providers, improving quality of care, and making services more affordable. APM participants receive payments that reward them for the value of—rather than the volume of—services provided. Value, in this context, is outcomes of the intervention as related to cost. Accountable Care Organizations (ACOs) are one type of APM that takes system-wide responsibility for the care of an individual across all their health care needs.

To incentivize ACOs to serve more beneficiaries from underserved communities CMS is proposing a Health Equity Benchmark Adjustment (HEBA) to be applied based on the number of beneficiaries they serve who are dually eligible or enrolled in the Medicare Part D Low-Income Subsidy (LIS).

CMS is proposing to require ACOs to report the APM Performance Pathway (APP) Plus Quality Measure Set. This would include the 6 measures currently in the APP quality measure set and incrementally incorporate the remaining 5 Adult Universal Foundation quality measures by the 2028 performance period/2030 payment year with preference for reporting electronically through electronic clinical quality measures (eCQMs).

New measures included in the APP Plus Quality Measure Set for Shared Savings Program ACOs that could involve audiologists and SLPs include:

#479 Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups beginning in PY 2025
#487 Screening for Social Drivers of Health beginning in PY 2028

CMS is also proposing a calculation methodology to account for the impact of improper payments when reopening a payment determination to recoup payments they believe were not properly earned.

Finally, CMS is seeking additional details from ACOs and other interested parties about the tradeoffs associated with a new higher risk / reward option than the current ENHANCED track.

Learn more about APMs and value-based care on ASHA’s website.

Merit-Based Incentive Payment System (MIPS)

CMS continues to focus on the transition from MIPS to MIPS Value Pathways (MVPs) by proposing new MVPs related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. They are consolidating the two neurology-focused MVPs into a single neurology MVP. They are also requesting information on challenges clinicians may face in adopting MVPs, data reporting for public health, and the use of Patient- Reported Outcome Measures (PROMs), Patient-Reported Outcome Performance Measures (PRO–PMs), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey. ASHA members can participate in MVPs as members of larger health care systems but not as individuals or as private practices because the current structure of MVPs does not allow for effective nonphysician participation.

CMS proposes to revise their cost measure scoring methodology to assess clinician cost of care more appropriately in relation to national averages. At this time, ASHA members are not required to participate in the cost performance category as there are no cost measures specific to audiology and speech-language pathology care management across an episode.

There are no changes to the audiology specialty measure set for the 2025 performance/2027 payment year.

We are pleased that CMS is proposing to add five measures to the speech-language pathology specialty measure set for the 2025 performance/2027 payment year in response to a request from ASHA last year [PDF]. Those measures include:

Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
Dementia: Functional Status Assessment: Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.
Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: (1) dangerousness to self or others and (2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.
Dementia: Education and Support of Caregivers for Patients with Dementia: Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences: Percentage of patients diagnosed with ALS who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, lawful physician-hastened death, hospice) or whose existing end of life plan was reviewed or updated at least once annually or more frequency as clinically indicated (i.e., rapid progression).

Clinicians continue to be excluded from mandatory MIPS participation if they have: 1) allowed charges for covered professional services less than or equal to $90,000, 2) furnished covered professional services to 200 or fewer Medicare Part B-enrolled individuals, or 3) furnished 200 or fewer covered professional services to Medicare Part B-enrolled individuals. Given these standards, ASHA estimates that less than 1% of its members are subject to MIPS.

Additional information on MIPS is available on ASHA’s website.

Next Steps for ASHA: ASHA will request CMS finalize its proposal to add 5 new measures to the speech-language pathology specialty measure set under MIPS.

Social Determinants of Health (SDOH)

SDOH describes “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Healthy People 2030).

CMS is requesting information on several new health-related social needs services including Social Determinants of Health Risk Assessment (SDOH RA) (HCPCS code G0136) currently used by primary care physicians. They are interested in the types of auxiliary personnel that are not adequately captured in current coding and payment for these services. They are also interested in any related services that billing practitioners and auxiliary personnel perform to address SDOH that may not be captured in current codes.

Z codes (ICD-10-CM codes Z55-Z65) are used to document an individual’s SDOH data and come in nine broad categories of SDOH known to affect patients’ health outcomes (e.g., housing, psychosocial, literacy). CMS is requesting information on the current utilization of Z codes, as well as barriers and opportunities to their widespread use.

Next steps for ASHA: ASHA supports collecting SDOH information to ensure patient needs are being met when these factors impact their experience and outcomes of care. Additionally, this information could help ensure payment adequately considers the impact of SDOH on the cost of care.

Find out more about SDOH on ASHA’s website.

Medicare Targeted Manual Medical Review

CMS notes that the Bipartisan Budget Act of 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review process first applied in 2015. Therefore, Medicare beneficiaries can continue to receive medically necessary treatment with no arbitrary payment limitations. However, clinicians must append modifier “KX” when medically necessary services reach a monetary threshold, which changes annually. For 2025, CMS estimates the “KX” modifier threshold will be $2,410 for physical therapy and speech-language pathology services combined. This represents an $80 increase from the 2024 threshold amount of $2,330. Find more information regarding the permanent repeal of the therapy cap and the current targeted medical review process on ASHA’s website.

What’s next?

ASHA will submit comments by the September 9 deadline. The final rule will likely be issued in early November with implementation on January 1, 2025. We will keep members informed on developments.