Takeaways from CMS’ proposed 2025 Physician Fee Schedule

The proposed 2025 Medicare Physician Fee Schedule (PFS) has lots to like for doctors of optometry, but physicians of all types are still being impacted by stagnant Medicare reimbursement.

When the Centers for Medicare & Medicaid Services (CMS) unveiled a week ago its proposed Physician Fee Schedule for next year, it was clear that years of AOA advocacy have led to the new proposed policies.

The AOA has long urged CMS to do more to include doctors of optometry in accountable care organizations (ACOs). CMS is proposing a new program to fund ACOs that expands the care offered in the ACO, including vision care.

Further, CMS is proposing a new add-on code for doctors who provide post-operative care. It would mean additional reimbursement for doctors of optometry involved in co-managing care with other surgeons.

Unfortunately, CMS also proposed a 2.8%-2.93% physician pay cut next year, rousing a round of reprovals from health care providers and other groups. The relative value unit for services provided would fall from $33.29 to $32.36. According to CMS, payments are “based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense and malpractice expense. These RVUs become payment rates through the application of a conversion factor.”

Steven T. Reed, O.D., AOA president, characterized the proposed physician fee schedule cut as disappointing and potentially devastating.

“Doctors of optometry are trapped between the proverbial rock and a hard place as the cost of providing patient care increases and Medicare reimbursement rates remain stagnant,” Dr. Reed says. “The AOA continues to advocate for our patients by urging Congress to find a solution to the problem rather than a patch.”

The PFS is Medicare’s primary method of paying health care providers participating in the program. Medicare uses the PFS when paying for professional services offered by health care providers in private practice, designated services covered by Medicare, diagnostic tests and radiology services. The AOA is continuing its advocacy efforts including backing legislation (H.R. 2474 – Strengthening Medicare for Patients and Providers Act) to create a system that maintains a permanent, annual update equal to the increase in the Medicare economic index.

CMS’ public comment period on the proposed changes ends Sept. 9.

ACOs and expansion of vision services proposal

The two most impactful proposals involve ACOs and co-management pay.

The CMS proposes to develop a new program to provide funding at the start of the year to ACOs in order to expand the care offered in the ACO setting including vision care and other categories of care. ACOs can apply for the funds. According to the proposed rule, “Direct beneficiary services like vision, hearing and dental, and other services that have a reasonable expectation of improving or maintaining the health or overall function of ACO beneficiaries, have the potential to further improve beneficiary outcomes, reduce costs, and improve beneficiary engagement and willingness to receive care from a provider affiliated with an ACO…”

It later adds: “For each performance year, ACOs would be permitted to use up to 50% of their estimated annual prepaid shared savings on staffing and healthcare infrastructure and up to 100% of their estimated annual prepaid shared savings on direct beneficiary services. ACOs must use a minimum of 50% of their prepaid shared savings on direct beneficiary services.”

Robert Theaker, O.D., member of the AOA Federal Relations Committee (FRC), reacted to the positive potential of the ACO proposal.

“CMS is hoping to improve ACO beneficiary health outcomes, reduce costs and improve beneficiary engagement and willingness to receive care from a provider affiliated with an ACO,” Dr. Theaker observes.

“As doctors know, ACOs consist of groups of health care providers who agree to work together to provide coordinated care to a group of patients,” he says. “Many doctors of optometry identify and participate in active ACOs in their regions or markets, and expansion of vision services would obviously be beneficial to optometrists seeking affiliation and participation in these groups. Look for more info to come, and a big thank you to our advocacy committees and AOA staff as we prepare comments to CMS regarding this important new rule.”

Proposal for add-on code for post-operative care

Under this proposal for a new add-on code, optometrists would be reimbursed for the complexity of providing care for a patient managed by multiple physicians when a formal transfer of care is not in place.

Patients benefit from post-operative care provided by their local optometrist as they already have an existing relationship with the patient creating more continuity of care, says Deanna Alexander, O.D., chair of the FRC.

“Currently, optometry is reimbursed one post-operative global fee that in reality is low,” Dr. Alexander says. “We appreciate that CMS recognizes the vital role optometry plays in post-operative care and the additional work required on patients to manage a successful surgical outcome.

“Some surgical patients may be more complex, require additional visits, and coordination of care during their post-operative global period,” she adds.

More takeaways for doctors of optometry

Other noteworthy takeaways from the proposed rule:

• CMS accepted the Relative Value Scale Update Committee (RUC) recommended values for Optical Coherence Tomography (CPT codes 92132, 92133, 92134 and 9X059).
• CMS is also accepting the RUC-recommended work Relative Value Units (RVU) for all seven codes in the Transcranial Doppler Studies code family.
• CMS is also proposing to require the use of the appropriate transfer of care modifier (modifier -54, -55, or -56) for all 90-day global surgical packages in any case when a practitioner plans to furnish only a portion of a global package.
• Last year, CMS developed a measure set for optometry and ophthalmology. This year, it is proposing to separate the two into their own specific measure sets.
• CMS proposed a new Complete Ophthalmologic Care Measures Value Pathway (MVP) for 2025. Doctors could use this set.
• CMS is proposing not to increase the Merit-based Incentive Payment System performance threshold for 2025. It seeks to maintain the current threshold to avoid a MIPS penalty of up to 9% at 75 points for the CY 2025 performance year/2027 MIPS payment year.

What happens next? CMS will be accepting comments on the proposals and will issue a final rule regarding these proposals in winter 2024.