A CMS Christmas Carol: The 2025 Final Rule and the Ghost of Medicare Future FAQ

Come in, clinician, and know me better! We recently hosted our annual Final Rule webinar and added some holiday flourish with a Dickensian twist as we paid tribute to A Christmas Carol. And while it’s hard to top Gonzo and Rizzo the Rat as guides, having Heidi Jannenga and Rick Gawenda on hand made for an incredible event filled with holiday cheer and, most of all, questions about how incoming rule changes will impact rehab therapists. There are so many, in fact, that we’d need more than the powers of Christmas spirits to get through them all in one hour, so we’ve compiled them all here. So warm yourself by the fire and get ready for a lot of reading.

2025 Medicare Part B Deductible

Do most secondary insurances cover the Medicare deductible?

Many secondary insurance plans will cover a patient’s Medicare deductible, but, as always, you need to check any specific plan to know for sure.  

Is the Medicare 10th visit note still required?

The Medicare requirement for a progress note by a patient’s tenth visit hasn’t changed. 

What is the best way to check the patient’s updated deductible amount?

You can check a patient’s deductible (along with other eligibility) by using the Medicare Administrative Contractor (MAC) online provider portal using billing agencies, clearinghouses, or software vendors, or the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS).

Therapy Threshold Calculation

When are they going to separate PT and speech reimbursements?

A great question! Unfortunately, we don’t have any way of knowing if and when CMS might decide to count PT and speech services separately for the purposes of the therapy threshold amount. 

WebPT tracks the threshold amount. Does it reset that amount if the patient was seen in 2024 and is continuing treatment in 2025?

Yes, the KX modifier tracking will reset on January 1, 2025.

If we have an optional ABN on file for a patient for dry needling, do we need to bill the code to Medicare with an ABN modifier?

I’ll quote our resident billing expert, John Wallace, from this blog on billing for dry needling:

“In the case of Medicare, as a non-covered service, you can collect from the patient at the time of service. You can use an ABN, and if the patient checks “option 1” (requesting that you bill the service to Medicare), bill the service with the GX modifier.” 

CY 2025 MPFS Final Rule & Conversion Factor

Does Medicare charge a lesser percentage for each unit charged during a visit, or does it pay each unit charged per visit at the 100% or allowed rate?

I believe you're referring to the Multiple Procedure Payment Reduction (MPPR) policy, which reduced the practice expense payment for multiple units as well as multiple procedures billed during a single day. You can read up on the policy in this guidance from HHS.    

How significant will the decrease be in the 97112 and 97530?

We turned to Rick Gawenda for this one, who answered, “If the Conversion Factor in 2025 was the same as it is in 2024, 97112 would see an approximate $0.66 decrease, and 97530 would see an approximate $1.00 decrease in their national payment amounts.”

Please briefly touch upon the CPT Codes you mentioned; which ones lowered or increased reimbursement rates?

As was mentioned during the webinar, CPT codes 97022, 97112, and 97530 all received negative practice expense (PE) RVU adjustments, while  codes 97012, 97014, 97016, 97018, 97032, 97033, 97034, 97035, 97110, 97113, 97116, 97140, 97533, 97535, 97537, and 97542 and HCPCS code G0283 received positive adjustments. 

Assistant Supervision

Will there be changes to reimbursement for PTAs in 2025?

There were no changes to reimbursement specific to PTAs within the 2025 final rule, save for the border changes to the conversion rate. As a reminder, you must affix the CQ modifier to services provided in whole or in part by PTAs, which will then be paid at 88 percent of the full rate. 

Telehealth

Is there a modifier for telehealth?

There are modifiers for telehealth, some of which depend on your setting. Gawenda states, “You still have to append the 95 modifier for telehealth services in which you use audio or video telecommunication.” According to CMS’s guide on telehealth services, “If you performed telehealth through asynchronous telehealth, add the telehealth GQ modifier with the professional service CPT or HCPCS code. You’re certifying you collected and sent the asynchronous medical file at the distant site from a federal telemedicine demonstration conducted in Alaska or Hawaii.” Also, as noted during the webinar, you must affix the 93 modifier for audio-only telehealth visits in which the patient does not consent to use video. 

How do you find out which practices are qualified rural providers? 

Under Medicare’s definition, a facility must undergo a certification process outlined by CMS to be a rural health clinic. Thus, a practice should be well aware if it is an RHC—meaning you can reach out to ask the question.  

If Medicare does not extend the telehealth provisions, will remote therapeutic monitoring codes still be billable?

Remote therapeutic monitoring (RTM) isn’t tied to telehealth, so the RTM codes should be unaffected by any changes to telehealth. 

If audio telehealth is allowed, can we use our iPhones to call patients?

Although there is no specific restriction against providers using smartphones for telehealth, if you’re working for a covered entity, you’re still required to follow HIPAA standards to protect PHI.  

What are the telehealth documentation requirements?

You should document a telehealth visit as you would a normal visit, with the addition of the correct POS codes. You can check out page 28 of this guide for more information. 

Plans of Care

Does the plan of care (POC) have to state # of days/week? Or can it state the total # of visits?

Per Gawenda, “For the POC, you do need to state a frequency. Duration can be written in number of weeks or number of visits.”

If a patient does not have an order to start therapy, do we still need to follow the procedure to send and get the initial POC signed? And if they do not sign it, show multiple attempts?

The final rule specifies that the new guidance applies to patients who have an order or referral from a physician for physical therapy services. Unfortunately, when it comes to direct access patients, you're still left trying to hunt down that signature. 

How will CMS know that the plan of care has been delivered to the physician within 30 days?  What are they looking for as proof that it was sent?

The answer appears to be that whatever forms of submission were acceptable to MACs in the past will remain so in the future. From page 588 of the final rule:

“We have not established and are not aware of a comprehensive listing of “acceptable” delivery mechanisms. However, since policies relating to POC delivery/transmission to the physician/NPP have been in place for many years, we will direct our contractors to continue to accept the same methods of delivery as they have in the past.”

If a physician sends a new PT order towards the end of the initial POC, can that not serve as certification for a subsequent POC?

No, according to Gawenda. 

If you are an outpatient hospital, does the eval being in the patient's chart suffice, or do you need to send the eval in EPIC/Cerner to the physician?

Gawenda states, “There has to be evidence that the evaluation that includes the plan of care was sent to the physician who wrote the referral/order for outpatient therapy services within 30 days of the initial evaluation.”

Do the changes for physician prescriptions apply to ORF?

As we noted in the webinar, the changes to plan of care certifications do not apply to Comprehensive Outpatient Rehabilitation Facilities (CORFs), since a physician must establish those plans of care. 

Can patients self-refer to physical therapy?

Yes, thanks to direct access.  

If a patient presents with an order that is 45-60 days old, can we use it as an order to start and not need a new order?

As noted in the webinar, CMS is not placing a time frame on how soon a patient must start treatment from the time of the order. 

Just to confirm, you will always need a POC? The order from the physician can not be used in place of the POC?

According to CMS, you are still required to submit a POC to the physician; the change simply allows the order to serve as certification for that POC provided you’ve sought the physician’s signature.  

The MD sends a prescription for PT 2x per week for 8 weeks. The PT evaluates the patient and creates the POC, which states 2x/week for 12 weeks. The POC is sent to the MD within 30 days, and the physician makes no changes.  Can the therapist treat the patient for up to 8 weeks or 12 weeks under this script/POC?

“In your example, the POC would be 2 times per week for 12 weeks,” says Gawenda.  

If Medicare requires a recertification every ten visits or 90 days, how would you see the patient two times a week for eight weeks? Wouldn't you need to do a recertification in the fifth week?

Gawenda states that “Medicare requires a Progress Report, at minimum, once every ten visits. The plan of care can be valid for up to 90 days.” 

Is it true a Medicare patient can get an evaluation without a referral but would need it for all follow-up visits or a signed POC? Does Medicare allow patients to go to a PT,  get an eval, and start treatment without an order from a physician?

The short answer is, it depends. As we explain in Medicare and Direct Access, there’s unlimited direct access and limited direct access. Under unlimited direct access, a provider can do an eval, formulate a POC, and start treating a patient without an order from a physician—provided that they get a physician's signature on the POC within 30 days. With limited direct access, PTs, in most instances, can only perform the initial eval and then wait for a referral or order from a physician; the exact restrictions depend on the laws in your state.   

If a patient is beyond their 90 days for treatment and it is determined they need more sessions, would I need to get a new order from the physician?

The new guidance from CMS on POC certification only applies to the initial plan of care, so if you reach a point in a patient’s treatment where recertification is required, you would have to proceed as you normally would in getting a physician to sign off on your POC.  

What is the easiest way to find requirements for signed POC requirements, 8 minute vs Rule of 8s, G0283 vs. 97014, AMA vs. CMS guidelines, etc.? Does anyone know where we can easily find these rules for Aetna Medicare, Humana Medicare, UHC Medicare, BCBSTotal, etc?

Unfortunately, my research didn’t turn up a compendium of MA rules for the different payers and plans, so for the time being, you might be best served by checking with each payer as needed.

Do Medicare Advantage plans have to follow the new CMS guidance on POC certification? 

Gawenda says, in brief, “No!” 

Does the script have to have duration? We get a lot that say "evaluate and treat."

Gawenda has this to say on the matter: “For the new initial POC requirements for traditional Medicare in 2025, if the Medicare beneficiary presents with an order/referral for outpatient therapy services, it must have the discipline of therapy on it and be signed and dated by the physician/nonphysician practitioner. When the therapist develops the plan of care, they will determine the frequency and duration based on their evaluation of the patient.”

New Caregiver Training Services Codes

Could you do a virtual visit and utilize caregiver training over video and audio?

As noted during the webinar, the caregiver training CPT codes 97550, 97551, and 97552 were added to the provisional telehealth list for 2025, so should telehealth flexibilities be extended via legislation for the next two years, rehab therapists would be able to use those codes during telehealth visits. 

Can caregiver training codes be used alone for an appointment with the caregiver, or must they be used in conjunction with a patient appointment and other codes? Is the caregiver training code only for wounds or also for transfer training, etc?

In light of these questions, it might be useful to look at the descriptions for the existing and newly-added caregiver training codes. 

97550: Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (eg, activities of daily living [adls], instrumental adls [iadls], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes

97551:  Each additional 15 minutes

97552: (Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers

G0541: Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; initial 30 minutes

G0542: Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) (Use G0542 in conjunction with G0541) 

G0543: Group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face with multiple sets of caregivers

For the new Caregiver Training Service Codes, and the requirement that the service be provided to an "unpaid" caregiver: does this include "private pay"? For example, if my patient hires a caregiver privately through a site such as Care.com, are they considered to be "paid" and therefore not eligible?

According to Gawenda, “They would not be eligible as they are being paid to take care of the patient.”

Can the caregiver training codes be used if the patient is present, or can they only be used if the patient is not there?

The caregiver training codes 97550-97552 as well as codes G0541-G0543 specify that the patient is not present during the training. 

How would you show them how to wrap/compression without them being there?

There is some degree of clinical judgment that might be required in providing caregiver training and using caregiver training codes. If you feel you cannot effectively demonstrate wrapping and compression virtually, then it may be more appropriate to do so during an in-person visit. 

Can we use the current CTS codes for all CTS training since the current and new codes are so close in the descriptors? When might we see a denial if one code was used versus the other?

As always, specificity is the key. Reference the descriptors listed above to find the most applicable to the training you’re providing.  

Can caregiver training be done with a place of service code of 12 when issuing DME at home?

Gawenda informs that “If doing the caregiver training with the caregiver in the home, the correct place of service code is a 12.”

Could the Caregiver training codes (without the patient) be billed on the same day as a regular therapy session with the patient? Would the caregiver training codes fall under a completely separate daily note?

The caregiver training codes can be billed the same day as regular treatment codes for traditional Medicare. Whether you want to write one or two notes would be the decision of the therapist or assistant. 

MIPS 2025 / MIPS MVP

How do we find out our MIPS score?

Eligibility for MIPS is determined using three criteria:

• Billing more than $90,000 for Medicare Part B covered professional services, 
• Seeing more than 200 Medicare Part B patients, and
• Providing more than 200 covered professional services to Medicare Part B patients.

If you fall below that threshold, you’re not required to participate in MIPS—but you can elect to do so if you wish. 

Are institutional providers (OPT ORF) going to be eligible to participate in MIPS?

While they may someday be eligible, currently providers in facility-based outpatient therapy and skilled nursing facility (SNF) settings are excluded from MIPS eligibility. 

When you say 16 or more (providers) under the same TIN, is that at one time? What if you only ever have 15, but one provider leaves your practice, and you hire a new provider? Does that now become 16?

“When CMS looks at each determination period, they will look at the number of NPIs assigned under that TIN. If, during that determination period, you have 16 or more NPIs assigned to that TIN (does not have to all be at the same time), you most likely will be considered a large practice,” Gawenda states.

Pending Legislation

If the bill (Medicare Patient Access and Practice Stabilization Act) is passed, will there still be a sequestration reduction to codes 97530 and 97112?

“Yes,” says Gawenda. 

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We covered quite a bit of ground in those questions! OK, maybe not as impressive as spanning the whole of one miser’s life before the sun comes up, but hopefully these answers are as enlightening as a trip through time with some Christmas spirits. If you want to revisit some of what Heidi and Rick talked about live, be sure to check out the replay of our Final Rule webinar.