2025 Medicare Physician Fee Schedule Final Rule

Effective January 1, 2025, the Centers for Medicare & Medicaid Services (CMS) has issued the 2025 Medicare Physician Fee Schedule Final Rule with key updates impacting Preventive Services for Medicare members.

These updates enhance access to critical preventive services for Medicare members, improving early detection and prevention of serious health conditions such as hepatitis B, colorectal cancer, and cardiovascular disease.

Healthfirst is committed to supporting providers in delivering high-quality preventive care to our Medicare members. Healthfirst will align reimbursement policies for Preventive Services with the updated Medicare Physician Fee Schedule.

Key Updates

CMS has expanded Medicare coverage for key preventive services, including Hepatitis B Vaccines, Colorectal Cancer Screenings, and Atherosclerotic Cardiovascular Disease (ASCVD) Risk Assessment Services. Learn more about the changes and how Healthfirst will align reimbursement according to new CMS guidelines:

Hepatitis B Vaccinations

• CMS has expanded access to vaccinations at no cost to Medicare members who are unvaccinated or whose vaccination status is unknown.
• Effective July 1, 2025, Rural Health Clinics (RHCs) will receive reimbursement for administering the vaccine at the time of service.
• Reimbursement for the vaccine and administration in RHCs and Federally Qualified Health Centers (FQHCs) will be at 100% of reasonable cost, separate from FQHC PPS or RHC AIR methodology.
• A physician’s order is no longer required for administration, allowing for roster billing by mass immunizers.

Colorectal Cancer Screening

• Medicare no longer covers barium enema screenings.
• Computed Tomography Colonography (CTC) is now a covered screening method with no Part B coinsurance or deductible when performed as a preventive screening. Screening CTC must be ordered in writing by the beneficiary’s attending provider
• Blood-based biomarker tests are included in Medicare’s colorectal cancer screening coverage.

Atherosclerotic Cardiovascular Disease (ASCVD) Risk Assessment Services

As part of the Medicare Physician Fee Schedule final rule, CMS has established coding and reimbursement for ASCVD risk assessment and management services to improve cardiovascular health outcomes.

• ASCVD risk assessments will be conducted alongside Evaluation & Management (E/M) visits for patients without a CVD diagnosis but identified as at risk.
• A new G-code (HCPCS code G0537) has been established for ASCVD risk management services, incorporating the "ABCS" of CVD risk reduction (aspirin, blood pressure management, cholesterol management, and smoking cessation) for patients at medium or high risk (>15% risk over 10 years).
• ASCVD risk assessments will not be separately billable for patients already diagnosed with cardiovascular disease or those with a history of a heart attack or stroke.
• CMS requires that the assessment tool used be standardized and evidence-based but does not mandate a specific tool.

How can providers prepare for these changes?

Providers are encouraged to familiarize themselves with the updated preventive service coverage and billing guidelines, including:

• Implementing updated protocols to align with new coverage policies
• Ensure proper documentation and coding for newly covered services to facilitate appropriate reimbursement
• Educate Medicare members on the availability of these expanded preventive services

More Information

For more details about the 2025 Medicare Physician Fee Schedule Final Rule updates to Preventive Services, visit: Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule | CMS

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm