Jigsaw Falling Into Place: Piecing Together the 2025 Final Rule

I don’t know about you, but I’m not a fan of surprises. Horror movies? That’s a hard pass from me. The dreaded “Call me” or Can you talk” text? I’d sooner drop my phone to the bottom of the ocean. And I know there are plenty of folks out there like me who’d much rather know what’s coming than have to sweat out a surprise, even on the chance it’s a good one. 

That’s what I respect about CMS’s Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule: they tell you in advance what to expect via the proposed rule. It’s not always great; in fact, it’s usually (but not always) more bad than good when it comes to rehab therapy. But at least you’re not left to worry over the course of the year what it’s going to say about how you can provide and bill for Medicare services. So come with me as I take you through new rules and regulations that we were mostly already expecting. And for the faint of heart, no alarms and no surprises, please. 

Dollars and cents: The conversion factor is going down. 

As expected, the conversion factor is dropping again this year. CMS revealed in the final rule that the 2025 PFS conversion factor will sit at 32.3465, down from $33.29 in 2024. Technically, the conversion factor is receiving a 0.02 percent positive budget neutrality adjustment (staggering, I know), but the overall number is declining because of the expiration of a temporary 2.93% payment increase for services furnished from March 9, 2024, through December 31, 2024. 

Little by little: The therapy threshold gets a slight increase.

At least we can count on the therapy threshold to increase year over year. The final rule set the threshold for therapy services at $2,410 for physical therapy and speech-language pathology services combined and $2,410 for occupational therapy services—up from $2,330 in 2024. The threshold for targeted medical review is $3,000 for physical therapy and speech-language pathology services combined and $3,000 for occupational therapy services through CY 2027, after which the number will increase based on the Medicare Economic Index. 

Here is where I must once again note that the $2,410 figure is a threshold, not a cap, for those folks who continue to refer to the figure as the latter. If services are still medically necessary beyond that amount, simply affix the KX modifier and document the necessity of the treatment. 

Let down: The 19 misvalued RVUs remained misvalued. 

If you’ve followed the saga of the 19 misvalued therapy RVUs dating back to last year’s final rule, you won’t be surprised to hear that CMS ultimately decided against matching the values suggested by the APTA and AOTA, as they said they wouldn’t in the proposed rule. Page 270 of this year’s final rule offers a fuller timeline of events if you’re curious about how the decision was arrived at by CMS and the Health Care Professionals Advisory Committee (HCPAC).   

Optimistic: Plan of care certification is a little easier.

Now, we’re into the good news portion of the recap. If you’ve ever had to harangue a primary care doctor for a signature on a plan of care, you can breathe slightly easier as of January 1. CMS finalized its proposal to allow for a signed/dated physician order or referral to count toward the physician signature requirement on a plan of care, provided that the therapist has documented the delivery of the POC to the physician within 30 days of completion of the initial eval.

However, you’re not entirely free of chasing down those Herbie Hancocks. CMS makes clear that they have no intention of creating exceptions to the rule for physician signatures on recertifications for a POC or for the signature requirement when treating direct access patients. Still, it’s a big win for rehab therapists. If you want to read CMS’s comments in full, check out page 549 of the final rule.      

All I need: Supervision guidelines get relaxed. 

Medicare’s direct supervision requirements for PTAs and OTAs were another long-standing bugbear for rehab therapists—and are also set to be a thing of the past. Proving once more that respectful yet consistent complaining can eventually win out, CMS finalized its proposal to relax supervision guidelines to general for PTAs and OTAs providing outpatient OT and PT services. As CMS itself notes, they are now in line with the guidelines set forth by a vast majority of states for PTA and OTA supervision. However, for those states where direct supervision is still mandated, CMS guidelines won’t supersede your state practice act—meaning that direct supervision is still the requirement. If you want to dig in deeper, check out page 542 of the final rule.    

In limbo: Virtual direct supervision sticks around…for now. 

While the pandemic introduced some curious things to the wider public (remember when everyone was into baking bread for a minute?), it did have the unintended positive effect of pushing healthcare into the twenty-first century when it comes to technology.  Virtual direct supervision was one of those things born out of necessity that clinicians quickly realized was pretty useful, even absent a public health crisis. 

Fortunately, CMS has seen fit to agree—at least partially. They have finalized their proposal to update the definition of direct supervision to include audio/video real-time communications, but only for a specific subset of incident-to services, including:  

• services furnished incident to a physician or other practitioner’s service when provided by auxiliary personnel employed by the billing practitioner and working under their direct supervision, and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’;10;  and 
• services described by CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional).

For all other services, virtual direct supervision remains in place only through December 31, 2025. We’ll have to see if CMS makes a more definitive policy in next year’s final rule or once again punts the decision for a year. Read what CMS had to say on direct virtual supervision on page 150 of the final rule.  

There, there: We have better guidance on caregiver training services.

Given their relatively recent introduction, caregiver training codes were bound to go through some fine-tuning this rule cycle—which is exactly what CMS has done.  

In the final rule, CMS clarifies that “when reasonable and necessary, assessing the caregiver’s skills and knowledge for the purposes of caregiver training services could be included in the service described by CPT code 96161.”

On page 328 of the final rule, CMS also notes that: 

“We are designating direct care CTS as “sometimes therapy” services to facilitate payment for CTS under the PFS for outpatient physical therapy, occupational therapy, and speech-language pathology services when personally furnished by PTs and OTs, including those provided by their supervised assistants as appropriate, as well as the CTS personally furnished by SLPs. This means, as we stated in the CY 2024 PFS final rule (88 FR 78920) for the other CTS codes, that the services described by these codes are always furnished under a therapy plan of care when provided by PTs, OTs, and SLPs; but, in cases where they are appropriately furnished by physicians and NPPs outside a therapy plan of care, that is, where the services are not integral to a therapy plan of care, they can be furnished under a treatment plan by physicians and NPPs.”

CMS is also confirming its update to consent rules to allow for verbal consent for caregiver training. Page 321 of the final rule has more on caregiver training updates for direct care and DME. 

Present tense: Telehealth privileges live to see another day. 

Telehealth is another pandemic-era service that remains in limbo with CMS, at least as far as rehab therapists are concerned. And like virtual direct supervision, CMS seems content to kick the can down the road as far as a permanent decision on telehealth privileges for therapists. 

As they state on page 122 of the final rule,

“(W)e are not considering in this rulemaking for CY 2025 whether to recategorize provisional codes as permanent because we intend to conduct a comprehensive analysis of all such provisional codes, which we expect to address in future rulemaking. We clarify that we will retain these Therapy/Audiology/Speech Language Pathology codes on the Medicare Telehealth Services List with a provisional status after the expiration on December 31, 2024, of current statutory PHE-related telehealth policies that have expanded the scope of practitioners that could furnish and be paid for telehealth services. After consideration of public comments, we are finalizing as proposed to maintain these services as provisional on the Medicare Telehealth Services List.”

The therapy codes included in the provisional list are: 

• 97161 Physical therapy evaluation, low complexity 
• 97162 Physical therapy evaluation, moderate complexity 
• 97163 Physical therapy evaluation, high complexity 
• 97164 Physical therapy re-evaluation 
• 97110 Therapeutic exercises, each 15 mins 
• 97112 Neuromuscular re-education, each 15 mins 
• 97116 Gait training, each 15 mins 
• 97530 Therapeutic activities, each 15 mins Physical Therapy 
• 97535 Self-care home management

CMS also includes caregiver training codes 97550, 97551, 97552, 96202, 96203 and HCPCS codes G0541- G0543 (GCTD1-3) and G0539-G0540 (GCTB1-2) on the provisional list.

They’re also carving out an exemption for audio-only telehealth in instances where a patient either does not have or does not consent to the use of video technology—which, permitted or not, could prove challenging for rehab therapists.

Like spinning plates: There’s a myriad of changes to MIPS. 

The data completeness and performance threshold remain the same. 

CMS is opting to keep the performance threshold (which is to say, the baseline number to not get a negative payment adjustment) at 75 points for CY 2025/payment year 2027. They’ve also announced that the data completeness criteria threshold is staying put at 75% for both CY 2027 and CY 2028, which are the 2029 and 2030 payment years.   

Data submissions must meet a certain minimum.

In addition to the overall data completeness requirements, CMS outlined guidance on minimum standards for individual submissions under the different MIPS categories:

Improvement Activities 

Data submissions must include numerator and denominator data for at least one MIPS quality measure for the quality performance category and include a response of “yes” for at least one activity in the MIPS improvement activities.

Promoting Interoperability

For the performance category, a qualifying data submission must include: 

• performance data, including any claim of an applicable exclusion, for the measures in each objective, as specified by CMS; 
• required attestation statements, as specified by CMS; 
• CMS EHR Certification ID (CEHRT ID) from the Certified Health IT Product List (CHPL); and 
• the start date and end date for the applicable performance period.

Improvement Activites are being simplified. 

CMS is also making changes to reporting and scoring for the Improvement Activities category, finalizing the proposal to eliminate the weighting of activities as well as reducing the number of activities to which clinicians are required to attest to be scored in the Improvement Activities performance category.

Some rehab-related quality measures have been revised. 

Of course, existing quality measures usually get some minor changes year to year. Here are the changes that rehab therapists should keep in mind for 2025. 

Quality #130: Documentation of Current Medications in the Medical Record

• The measure description is revised to read: For all collection types: Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
• Updated guidance: For the eCQM specifications collection type: Revised: allows for documentation to be completed on the day of the encounter.
• Updated initial patient population: For the eCQM specifications collection type: Removed: age criteria.
• Updated denominator: For the MIPS CQM Specifications collection type: Removed: age criteria.
• Updated denominator criteria: For the MIPS CQM Specifications collection type: Removed: age criteria. Added: coding for pediatric audiology services.
• Updated numerator note: For the MIPS CQM Specifications collection type: Revised: allows for documentation to be completed on the day of the encounter.

Quality #155: Falls: Plan of Care

• Modified collection type: MIPS CQM Specifications collection type (not Medicare Type B Claims Measure)

Quality #181: Elder Maltreatment Screen and Follow-Up Plan

• To Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences–Modified*: clarification that the list of standardized tools is not exhaustive.

Quality #281: Dementia: Cognitive Assessment

• Updated guidance: Added: The measure requires a diagnosis of dementia is present before the routine assessment of cognition once in a 12-month period.

Quality #282: Dementia Functional Status Assessment

• Updated denominator criteria: Added: coding for speech language pathology and nuclear medicine.

Quality #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

• Updated denominator criteria: Added: coding for speech language pathology and nuclear medicine.

Quality #288: Dementia: Education and Support of Caregivers for Patients with Dementia

• Updated denominator criteria: Added: coding for speech language pathology and nuclear medicine.

Quality #281: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease (PD)

• Updated denominator criteria: Added: coding for neuropsychology, behavioral health, and physical and occupational therapy.

Quality #293: Rehabilitative Therapy Referral for Patients with Parkinson’s Disease

• Updated denominator criteria: Added: coding for neuropsychology, behavioral health, and speech-language pathology.

Quality #498: Connection to Community Service Provider Category

• Updated denominator criteria: Added: coding for Dentistry, Emergency Medicine, Inpatient, Nuclear Medicine, Interventional Radiology, Psychiatry, Mental and Behavioral Health, Nephrology, Nutrition/Dietician, Obstetrics/Gynecology, Ophthalmology, Otolaryngology, Physical Therapy/Occupational Therapy, Home Care and Skilled Nursing. 

The MVPs are adding six new members. 

QPP continues to develop the MIPS Value Pathways (MVP) program as they prepare to transition away from the traditional MIPS program in a few years. This year, they’re adding six new MVPs—although none that are evidently relevant to rehab therapists. 

• Complete Ophthalmologic Care
• Dermatological Care
• Gastroenterology Care
• Optimal Care for Patients with Urologic Conditions
• Pulmonology Care
• Surgical Care

The Rehabilitative Support for Musculoskeletal Care MVP is getting some updates. 

Rehab therapy may only have one MVP, but what an MVP it is! (One might call it the MVP of MVPs.) Okay, maybe that’s a bit over the top, but it can be tough to parse hundreds of pages of MIPS updates with scant few mentions of physical therapy, occupational therapy, or speech-language pathology. Fortunately, there are some changes to the MSK MVP to report on.  

New Quality Measures:

• Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
• MSK6: Patients Suffering From a Neck Injury who Improve Pain
• MSK7: Patients Suffering From an Upper Extremity Injury who Improve Pain
• MSK8: Patients Suffering From a Back Injury who Improve Pain
• MSK9: Patients Suffering From a Lower Extremity Injury who Improve Pain

New Improvement Activity:

• IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B

Removed Improvement Activity:

• IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

While CMS had initially proposed to remove IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop, they stated that they are delaying it based upon comments. 

Exit music (for a blog).

Well, that’s the basics of what you need to know about the 2025 final rule as it relates to your rehab therapy practice. If you want a more in-depth discussion on the rules and what they mean from a couple of industry experts, be sure to save the date for our final rule webinar on December 16, featuring Heidi Jannenga and Rick Gawenda. Registration will be available soon!