Navigating the 2025 Final Rule: Key Changes and Expert Insights

INTRODUCTION 
The 2025 Medicare Physician Fee Schedule (PFS) Final Rule introduces significant changes that directly impact reimbursement, telehealth services, care delivery models, and compliance requirements. This eBrief breaks down the most important updates and offers strategies to help your organization adapt, stay compliant, and continue providing the best patient care. 

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MEDICARE PAYMENT RATES 
Medicare reimbursement cuts are among the most impactful changes in the 2025 Final Rule:  

• Payment Cuts: Average payment rates under the PFS will drop by 2.93% in 2025. 

• Lower Conversion Factor: The new rate is $32.36, reflecting a 2.83% decrease from 2024. 

• Potential Legislative Fix: The proposed Medicare Patient Access and Practice Stabilization Act of 2024 (H.R. 10073) aims to halt these cuts. Learn more at fixmedicarenow.org. 

TELEHEALTH SERVICES  
After years of expanded access, telehealth regulations are tightening:  

• Return of Geographic and Site Restrictions: Starting January 1, 2025, telehealth services will be limited to rural areas and specific medical settings. 

• Approved Telehealth Locations: 

• Physician offices, hospitals, CAHs, renal dialysis centers, RHCs, FQHCs, SNFs. 

• Patients' homes are no longer valid originating sites. 

• Behavioral Health Exceptions: Behavioral health telehealth services remain exempt from geographic restrictions and can be delivered via audio-only platforms. 

• RHC/FQHC Use of G2025: RHCs and FQHCs can bill G2025 for telehealth distant site services. 

• Updated Codes: 

• Deleted: CPT codes 99441–99443. 

• Introduced: Codes 98000–98015 for audio and video visits. 

• CMS will not reimburse these codes except for 98016 (virtual check-in), replacing G2012. 

 
NEW AND REVISED CPT/HCPCS CODES  
To reflect evolving needs, several new and updated CPT/HCPCS codes have been introduced:  

G0561: Tympanostomy with Specialized Devices 

• Simplifies ear tube placement for pediatric patients (6 months and older) in office settings without general anesthesia. (Work RVU: Not assigned) 

G0545: Inpatient Infectious Disease Care Complexity 

• For patients with confirmed or suspected infectious diseases in inpatient or observation settings. 

• Includes disease transmission risk assessment, mitigation, public health coordination, and antimicrobial therapy. 

• Typically reported by infectious disease specialists (Work RVU: 0.89) 

G0539–G0543: Caregiver Training in Behavior Management 

• G0539: Covers the initial 30 minutes of face-to-face caregiver training in behavior management/modification for caregivers of patients with mental or physical health conditions. This training is administered by a physician or qualified healthcare professional, and the patient does not need to be present. (Work RVU: 1.00) 

• G0540: Adds 15-minute increments of caregiver training, to be used with G0539 for extended sessions. (Work RVU: 0.54) 

• G0541: Provides 30 minutes of face-to-face caregiver training in direct care strategies to prevent complications (e.g., ulcer formation, wound care, infection control) for patients with ongoing conditions. The patient does not need to be present. (Work RVU: 1.00) 

• G0542: Each additional 15 minutes; list separately in addition to code for primary service. Use G0542 in conjunction with G0541. (Work RVU: 0.54) 

• G0543: Offers group caregiver training in direct care strategies for multiple caregivers, focusing on preventing complications. This service is delivered face-to-face without the patient present. (Work RVU: 0.23) 

G0537–G0538: ASCVD Risk Assessment and Management 

• These codes support cardiovascular risk assessment and proactive management. 

• G0537: 5–15-minute cardiovascular risk assessment. (Work RVU: 0.18) 

• G0538: Ongoing risk management for patients at high risk for heart disease. (Work RVU: 0.18) 

G0560: Safety Planning Interventions 

• 20-minute personalized safety planning for patients at risk of suicide or substance use crises. (Work RVU: 1.09) 

G0544: Post-Discharge Behavioral Health Follow-Up 

• Monthly telephonic check-ins for patients discharged after a behavioral health crisis. (Work RVU: 1.00) 

G0552–G0554: Digital Mental Health Treatment (DMHT) 

• G0552: Supply and onboarding for DMHT devices. 

• G0553: First 20 minutes of treatment management. (Work RVU: 0.62) 

• G0554: Additional 20-minute increments. (Work RVU: 0.61) 

 
G0546–G0551: Behavioral Health Services 

• G0546: 5–10 minutes of interprofessional consultative discussion and review for mental health diagnosis and treatment, including a verbal and written report. (Work RVU: 0.35) 

• G0547: 11–20 minutes of consultative discussion and review. (Work RVU: 0.70) 

• G0548: 21–30 minutes of consultative discussion and review. (Work RVU: 1.05) 

• G0549: 31 or more minutes of consultative discussion and review. (Work RVU: 1.40) 

• G0550: 5 or more minutes of consultative time, including a written report to the patient’s treating/requesting practitioner. (Work RVU: 0.70) 

• G0551: 30 minutes of consultative discussion and review, including a written report to the patient’s treating/requesting practitioner. (Work RVU: 0.70) 

 
G0559: Post-Op Follow-Up Care (Non-Operating Provider) 

• Covers post-operative care during the 90-day global period when managed by a provider who did not perform the surgery. List separately from office/outpatient Evaluation & Management (E/M) visits (new or established). (Work RVU: 0.16) 

 Key Components: 

• Review Surgical Notes: Analyze reports to assess procedure success, affected anatomy, and potential complications. 

• Conduct Procedure Research: Understand expected recovery and risks, especially when outside the provider's specialty. 

• Perform Physical Evaluations: Examine the patient to monitor recovery progress. 

• Collaborate with the Surgeon: Contact the original surgeon if any concerns about the patient’s recovery arise. 

 
RURAL HEALTH CLINICS (RHCS) AND FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)  

RHCs and FQHCs face key billing updates to improve care coordination, service tracking, and preventive care coverage:  G0511: Care Management Billing Updates  

• Effective July 1, 2025, RHCs and FQHCs must bill individual care management codes instead of the bundled G0511 code. 

• This change improves tracking and recognition of care services provided. 

• G0511 covered 20+ minutes of clinical staff time for chronic care or behavioral health services directed by a provider. 

 
G0556–G0558: Advanced Primary Care Management (APCM) Services 

• G0556: Advanced care management by clinical staff under physician oversight. (Work RVU: 0.25) 

• G0557: Care coordination for patients with two or more chronic conditions. (Work RVU: 0.77) 

• G0558: Enhanced care management for Qualified Medicare Beneficiaries (QMB) with chronic conditions. (Work RVU: 1.67) 

 Immunizations 

• RHCs and FQHCs can now bill for Part B preventive vaccines during patient visits. 

• Covered vaccines include pneumococcal, influenza, hepatitis B, and COVID-19. 

 Medical & Dental Services on the Same Day 

• RHCs/FQHCs can bill for both medical and dental services provided on the same day. 

• Use the KX modifier to indicate the medical necessity of dental services, ensuring proper documentation. 

• Additional billing guidance will be provided by CMS in future updates. 

OTHER NOTABLE CHANGES  
Key updates improve billing, care delivery, and service access across multiple areas:  

Assistant at Surgery 

• 37211, 37212: Transcatheter therapy, arterial or venous infusion for thrombolysis. 

• 37242: Vascular embolization/occlusion. 

• 37197: Transcatheter retrieval of intravascular foreign body. 

• Note: Assistance is allowed only with documentation of medical necessity and only in particularly challenging cases. 

 Complex Non-Chemotherapy Drug Administration 

• Clarifies that certain biologics and infusion drugs can be billed using chemotherapy administration codes (96401–96549) when appropriate. For example: Rheumatology related conditions. 

• CMS will update the Medicare Claims Processing Manual to reflect this. 

 G2211 Code Expansion 

• G2211 can now be billed with office/outpatient E/M visits (99202–99205, 99211–99215) provided on the same day as: 

• Annual Wellness Visits (AWV) 

• Vaccine administration 

• Medicare Part B preventive services 

 
PT/OT Supervision  

• General Supervision Approved: Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (OTAs) can now operate under general supervision by therapists in private practice. 

• Enhanced Flexibility: This change allows therapists to better accommodate patient availability and ensures continued access to essential therapy services. 

• Billing and Reimbursement: Therapists in private practice can now bill and receive Medicare payments for services provided by PTAs and OTAs even when the supervising therapist is not physically present in the office or patient’s home. 

Dental & Oral Health  

• Expanded Coverage: Medicare now covers certain dental and oral health services related to medical conditions, supporting whole-person care. 

• Covered Procedures: Includes jaw reconstruction and pre-surgical dental clearances linked to medical treatments. 

• Approved Services: 

• Dental/oral exams before or during Medicare-covered dialysis for end-stage renal disease (ESRD). 

• Medically necessary procedures to eliminate oral or dental infections before or during dialysis treatment. 

• KX Modifier: Will eventually be required to confirm medical necessity; providers are encouraged to use it now for proper documentation. 

Global Surgery Modifiers 54, 55, and 56 

• Modifier 54: Required for all 90-day global surgical packages when only the surgical procedure is performed, covering both formal and informal care transfers. 

• Modifier 55: Used exclusively for post-operative care following a documented formal transfer of care. 

• Modifier 56: Applied solely for pre-operative care when a formal transfer of care has occurred. 

IMPLICATIONS FOR HEALTHCARE LEADERS  
Understanding the changes is only the first step — here’s how your organization can respond strategically.  

• Prepare for Payment Cuts: Review billing and coding processes in response to the PFS reduction. 

• Adjust Telehealth Strategies: Adapt to geographic restrictions while leveraging behavioral health flexibilities. 

• Train Your Team: Educate staff on updated CPT/HCPCS codes and billing changes. 

• Strengthen Compliance: Align documentation with new regulations and track legislative updates like H.R. 10073. 

HOW AAPC CAN HELP  
AAPC is here to support your healthcare organization in successfully managing the complexities of the 2025 Final Rule. Our solutions include:  

1. Revenue Cycle Optimization: Strengthen billing and coding practices to protect your bottom line. 

2. Corporate Team Training: Ensure your staff are fully prepared for new coding and billing requirements. 

3. Audit Services: Identify and correct compliance gaps before they become costly errors. 

4. Regulatory Compliance Support: Stay up to date with Medicare, Medicaid, and commercial payer regulations. 

5. Consulting Services: Develop and implement strategic responses to policy changes. 

CONCLUSION  
The 2025 Medicare Final Rule presents both challenges and opportunities for healthcare organizations. By understanding the key changes and proactively adapting strategies, you can protect your organization’s revenue streams, ensure compliance, and continue to deliver high-quality patient care. Partnering with AAPC provides the expertise and support to navigate this evolving landscape with confidence.   


REFERENCES  

• CMS

• AAPC

• HHS

• CMS