HUNT VALLEY, MD – November 21st, 2024 –
HealthPRO-Heritage is dedicated to helping our customers and teams understand the impact of the CMS Final Rule. We strive to keep everyone informed to effectively navigate shifts and continue to deliver high-quality, compliant and compassionate care to our patients. Each of our divisions will collaborate closely with their customers in order to ensure a full understanding of the updates and provide guidance on any recommended changes to current processes.
Key Updates
- New payment rates and conversion factor for 2025
- KX modifier increase
- Telehealth wins and potential losses
- Updates to Caregiver Training Services (CTS)
- Supervision changes for outpatient therapy assistants
- Eased certification requirements for therapy plans of care
- New Home Health Payment Rates for 2025
- Home Health Conditions of Participation Transparency
- Mandatory OASIS reporting
New Payment Rates and Conversion Factor for 2025
Change: Payment rates will reduce by 2.93% in 2025 due to the expiration of the 2024 temporary increase. The finalized Medicare Physician Fee Schedule (PFS) conversion factor for 2025 will be $32.25, down from $33.29 in 2024. Congress can still intervene before the cut takes place on 1/1/2025. The overall rate cut from 2020 to the proposed 2025 rates is 10.33%.
Impact: Understanding the impact of reimbursement reductions is important to ensure that we continue providing needed skilled care to our patients that is both efficient in delivery and focused on patient outcomes. A focus on coding accuracy is important when facing a reduction in reimbursement.
KX Modifier Increase
Change: KX modifier for 2025 increased from $2,330 to $2410 for PT/SLP combined services and $3,000 for OT services. The threshold for targeted medical review remains at $3,000 for PT/SLP and OT services through 2027.
Impact: Continue to utilize the KX modifier for services that would exceed therapy cap amounts or claims will be automatically denied. The KX modifier is an attestation by the therapist that the patient continues to require medically necessary services beyond the payment threshold. Therapists need to ensure the rationale for the extended therapy services are clearly documented.
Telehealth Wins and Potential Losses
Change: Without congressional action before 1/1/2025, current telehealth flexibilities will revert back to pre-COVID status. Therapists will only be qualified to deliver telehealth if a Medicare patient is located in a health professional shortage area, a rural census track, or a county outside of the Metropolitan Statistical Area at the time of service.
Impact: It is highly likely that Congress will continue the current telehealth flexibilities through 2027. If that is not the case, patients can only be treated in-clinic or via Home Health unless living in a qualifying rural area. The below telehealth changes will all go into effect on 1/1/25, but we await a decision from Congress on whether telehealth will continue as-is or only in rural areas. We will provide updates as we receive them.
Change: CMS will allow Medicare telehealth services to include two-way, real-time audio-only technology if the patient is either unable to use video technology or does not consent to video technology. Services must be provided to the patient in their home. If Congress allows telehealth flexibilities to continue, audio-only communication will be a new option for therapists.
Impact: The new audio-only option would allow therapists to provide education and instruction to their patients who are otherwise limited by lack of video technology use. However, most CPT codes require visual observation and the use of audio-only communication would be limited. The use of a 93 modifier is required for audio-only communication.
Change: Caregiver Training Services (CTS) codes were added to the Medicare Telehealth Services List. CPT codes 97550, 97551, 97552, 96202 and 96203 are now able to be provided virtually. Codes 97550 – 97552 pertain to education of one or more caregivers to enhance patient functional performance. Codes 96202-96203 pertain to education on behavior management/modification in a group setting.
Impact: Telehealth therapists can now bill for time spent educating patients and caregivers on proper home care techniques/behavior management. Therapists can focus on equipping patients and families with tools needed for successful outcomes.
Updates to Caregiver Training Services (CTS)
Change: Consent for CTS can now be provided verbally by the patient or their representative. This consent applies to CPT codes 97550, 97551, 97552, 96202 and 96203.
Impact: This aligns with the new addition of CTS codes to telehealth, further empowering therapists to utilize caregiver training as a tool to improve outcomes and reduce risk of readmission.
Supervision Changes for Outpatient Therapy Assistants
Change: Physical and Occupational Therapy Assistants now only require general supervision rather than direct supervision in a private practice/outpatient setting. Previously, direct supervision (a PT/OT present in the same office and immediately available to assist) was required. Now the requirement is that a PT/OT is immediately available via real-time audio or audio/video communication.
Impact: This provides group practice/outpatient clinics more flexibility in meeting the scheduling needs of beneficiaries and safeguards patient access to medically necessary therapy services, including those with challenges accessing these services in rural and underserved areas. This update by CMS would not supersede your state practice act if it is more stringent. By utilizing general supervision effectively, practices can maintain high-quality care and improve resource allocation.
Eased Certification Requirements for Therapy Plans of Care
Change: If there is a physician or non-physician practitioner (NPP) order on file, therapists no longer require a separate signature on the initial treatment plan. A signed/dated physician order or referral counts toward the physician signature requirement on a POC. The treatment plan must be transmitted to the physician/NPP within 30 days of the initial evaluation. Subsequent UPOCs require signature within the established 30- day time frame.
Impact: This reduces the burden to obtain signatures from physicians/NPPs on initial POC prior to initiating care. This will reduce delays in therapy initiation and reduce risk of payment denials due to potential administrative delays as a result of non-signature on the plans of care.
New Home Health Payment Rates
Change: There is a 2025 payment update of 2.7% ($445 million increase), which is offset by an estimated 1.8% decrease that reflects the permanent behavior adjustment ($295 million decrease) and an estimated 0.4% decrease that reflects the updated FDL ($65 million decrease). CMS estimates that Medicare payments to HHAs in 2025 would increase in aggregate by 0.5% ($85 million) compared to 2024.
Impact: While not as harsh of a reduction compared to what was proposed, CMS has now initiated cuts in three consecutive years. HHAs must focus on efficiency and effectiveness of skilled care, providing patients with high-level care while continuing to manage reduced payments.
Home Health Conditions of Participation (CoP) Transparency
Change: Home Health agencies now have a new Condition of Participation standard that was finalized in the 2025 Final Rule titled the Acceptance to Service Policy. This new standard requires the agency to develop, implement, and maintain an acceptance-to-service policy that is applied consistently to each prospective patient referral. This policy must address at a minimum:
- The anticipated needs of the referred patient
- The home health agency’s case load and case mix
- The home health agency’s staffing levels
- The skills and competencies of the agency’s staff
Impact: The goal of the Acceptance to Service Policy is to improve the referral process and reduce care delays by helping to ensure referring entities and potential patients can select the right agency based on their care needs. This Policy makes it imperative that HHAs adequately staff with skilled therapists experienced in all high-demand competencies.
Mandatory OASIS Reporting
Change: Home Health Agencies must submit OASIS data for all patients, regardless of payer, beginning July 1, 2025, and may voluntarily submit beginning January 1, 2025. All payers will then be included in your outcome calculations after July 1, 2025
Impact: We recommend beginning the OASIS all-payer data collection and submission process prior to the required date of July 1, 2025 to ensure that processes, export schedules and staffing levels have been addressed well ahead of the requirement deadline. These outcomes will impact your Starratings and your Value-Based Purchasing Outcome calculations.
Find the full 2025 PFS/Part B Final Rule here
Find the full 2025 HH Final Rule here