An Overview of CMS 2025 Final Rules – Important Information for the SVU Member
By Anne Jones, BSN, RVT, RDMS, FSVU, SVU Advocacy Chair
The SVU Advocacy Committee has been busy since July reviewing the Centers for Medicare and Medicaid Services (CMS) annual proposed rulemaking, gathering survey data to formulate a response, submitting comments, and analyzing the final rulemaking for 2025 payment rates. This summary is provided to provide a brief synopsis of the process and outcome.
By way of background and as a refresher about terminology, the Balanced Budget Act of 1997 granted authority to CMS to establish a prospective payment system for hospital outpatient services. Further modifications were granted under the Balanced Budget Refinement Act of 1999 and other legislation. The main intent was to provide CMS with a system to better predict and manage program expenditures by assigning fixed payment amounts to groups of services similarly to the inpatient prospective payment system (based on Diagnosis-Related Groups). This information is available on the CMS.gov website.
The hospital outpatient prospective payment system (OPPS) in place today classifies all hospital outpatient services into Ambulatory Payment Classifications (APCs). Healthcare Common Procedure Coding System codes (HCPCS codes) are assigned to APCs by CMS, and these assignments are updated at least annually.
In contrast, free standing clinics and imaging centers are paid through the Physician Fee Schedule (PFS). This system is closer to the traditional fee-for-service system, where each code is assigned a reimbursement. However, CMS is increasingly bundling payments or capping payments under the PFS as well. So this is where we are today.
In July 2024, CMS published Proposed Rules updating the PFS and OPPS in the Federal Register. These proposed rules modify existing regulations, propose entirely new regulations, or announce new policies. They also propose payment rates for the upcoming calendar year. Once published, public comments are solicited.
Under the direction of our Regulatory Legal Counsel at Sidley Austin, SVU Advocacy Committee Members met by conference call to discuss our concerns over the Proposed Rule. This year, the most significant impact to SVU members was the change to the body of Transcranial Doppler codes: 93886, 93888, 93890, 93892 and 93893. In general, CMS cut reimbursement to these codes and added three add-on codes for certain types of TCD. Elizabeth Hardcastle and George Maliha M.D. of Sidley Austin noted that CMS had accepted results from the AMA RUC concerning TCD use and applications. They suggested that SVU conduct a member survey to assess utilization of TCD in actual clinical settings. 191 of you participated in this robust and informative survey that served as a basis for our rebuttal to CMS. In addition to our SVU members, the survey was distributed to TCD providers within the SDMS and ASN. We are grateful for their support and participation.
Summary of Results:
Based on this robust survey, the time respondents spent performing TCD studies did not concord with CMS’ estimates. CMS systematically overcounted time at the PAC station and undercounted time in the ultrasound room. Survey respondents also noted that TCD can be quite heterogenous depending on patient compliance, competing studies/patient activities, difficulties in obtaining intravenous access, among other factors. We also found that many centers do not perform the add-on procedures.
Despite SVU’s robust response, CMS chose to adopt the proposed changes to the codes from the AMA. While acknowledging our comments and survey, CMS did not change its proposal. Unfortunately, CMS finalized payment rates that reduce the “base studies” that our members most often perform:
1. TCD code 93886-TCD of the intracranial arteries: complete study
2. TCD code 93888-TCD of the intracranial arteries: limited study
3. TCD code 93892-TCD of the intracranial arteries: emboli detection without IV microbubble injection
4. TCD code 93893-TCD of the intracranial arteries: emboli detection with IV microbubble injection.
Of additional importance, CMS will no longer recognize code 93890-TCD study of the intracranial arteries: vasoreactivity study. Instead, there will be three add-on codes which should be listed separately in addition to the code for the primary procedure, most likely 93886 or the complete TCD study:
5. TCD code 93896-Vasoreactivity study performed with TCD of intracranial arteries: complete
6. TCD code 93897-Emboli detection without intravenous microbubble injection performed with TCD of the intracranial arteries: complete.
7. TCD Code 93898-Venous-arterial shunt detection with intravenous microbubble detection performed with TCD study of the intracranial arteries: complete.
Performing an add-on AND base study will result in higher reimbursement.
In addition to the changes to TCD, proposed 2025 payment amounts under the PFS will be reduced across the board by 2.93%. For those of you who like to wander through the weeds of policy, this means that for calendar year (CY) 2025, the PFS Conversion Factor (CF)-the dollar amount used to convert a service’s relative value units (RVUs) into a dollar payment, essentially determining the Medicare reimbursement amount for that service-will be reduced. The CF will be $32.3465, which reflects a decrease of $0.941 from 2024. OPPS rates will generally rise 2.9%.
So you ask: Is there any good news for SVU Members? The answer is yes! For Ankle-Brachial Indexes and Vein Mapping studies, no major changes were identified. In addition, preventative care services – such as AAA screening – continue to be “an area of interest for CMS” as it continues to refine preventative care policies to expand access. Time will tell.
One final comment worth noting: Congress must address certain funding bills when they return to Washington this year before funding expires. There are several schools of thought, though no crystal ball. Will they pass a strict Continuing Resolution to cover the next few months with no additional bills or policies or will that potentially be expanded? Could these payment rates be adjusted? Other issues addressed? We will simply have to monitor closely, and act as needed.
What are the next steps? While CMS did not accept our survey results concerning TCD use, SVU will plan to revisit this issue either by the end of CY 2024 or the first quarter of 2025. Now would be a great opportunity to contribute to the SVU Advocacy Fund, so that travel to CMS is possible!
Thank you for your participation in our SVU Advocacy survey, and keep in mind that issues impacting your reimbursement are of paramount importance to the members and our Advocacy Committee. We welcome your input and please reach out with questions or comments.
