Medicare 2025 Outpatient and Physician Fee Schedule Proposed Rules

The Medicare 2025 Hospital Outpatient and Physician Proposed Rules were released earlier this month.  ISASS will be commenting by September 9, 2024 on a number of spine surgery-related issues in the proposed Physician rule in particular, including the following:

• The osteotomy CPT codes (22210, 22212, 22214, 22216) have been nominated for review as “potentially misvalued”. The following paragraph from the Physician Rule describes the issue and the proposal by CMS:  “Overall, based on the six reasons provided by the nominator, along with the fact that these codes were last valued almost 30 years ago, and given the identified billing practices, we concur that CPT codes 22210, 22212, 22214, and 22216 are potentially misvalued. The nominator suggested two options to address this concern: (1) developing add-on codes to differentiate between the number of vertebral segments involved in the osteotomy procedure and whether it occurs in the cervical, thoracic, or lumbar regions; and (2) removing the current posterior osteotomy codes and incorporating osteotomies into new deformity fusion codes, both with and without osteotomy. We are proposing to consider this code family as potentially misvalued and we appreciate the detailed information submitted by the nominator with sufficient supporting evidence. We believe that this code family would benefit from a comprehensive review by the RUC, and we welcome comments on a broader understanding of these codes. Additionally, we seek input on current standard billing practices. For example, information on whether the standard of practice has evolved over time, and if so, how it has evolved, could aid in identifying potential coding issues related to this matter.” (here; pp 66-67)
• Additionally, CMS is requesting input on the definition of the SI joint fusion codes. As discussed above, CMS is also seeking clarity on the use of the SI joint fusion codes.
• CMS is also considering another proposed reduction in the conversion factor for physicians. CMS is proposing a 2025 conversion factor of $32.36, a decrease of 2.8% from the current conversion factor. Congress has provided temporary partial fixes to physician payment in the last few years, but that relief will expire at the end of 2024 unless additional legislation is passed.