Background

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a rule finalizing changes for Medicare payments under the Physician Fee Schedule and other Medicare Part B policies, effective on or after January 1, 2025.

This topic summarizes selected items from the CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule that wound care providers may find relevant. 

CY 2025 Medicare PFS Final Rule: Essential Updates for Wound Care Professionals

Medicare Payment Reductions

• Average payment rates under the PFS will decrease by 2.93% in 2025. The conversion factor is set at $32.35, down from $33.29 in 2024.

Caregiver Training Services (CTS)

• New coding and payment for caregiver training. The training can be related to wound care, pressure ulcer prevention, infection control, and behavior management and modification, but is not limited to these topics. Codes and payments to complete caregiver training via telehealth will also be available. 
• Coding, descriptors and requirements are summarized below:
• 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 (1 RVU)
• 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).
• Caregiver training may be appropriate for circumstances where a beneficiary’s caregiver needs training, but the patient is under a home health plan of care, receiving at-home therapy, or receiving DME services for unrelated conditions. CTS would not be billable for caregiver training that is already being separately billed for patients under a home health plan of care, receiving at-home therapy, or receiving DME services for involved medical equipment and supplies. We seek to avoid potentially duplicative payment
• G0541, G0542, and G0543 are designated as “sometimes therapy” services
• Telehealth: These codes were added to the Medicare Telehealth Services List to accommodate a scenario in which the practitioner completes the caregiver training service via telehealth.
• Patient Consent: treating practitioner must obtain the patient’s (or representative’s) consent for the caregiver to receive the  CTS and that the identified need for CTS and the patient’s (or representative’s) consent for one or more specific caregivers to receive CTS be documented in the patient’s medical record. CTS can be provided verbally by the patient (or representative). 
• Possible ways CTS may be incorporated into a wound healing program: 
• Wound Care: Train a caregiver not available to come to the clinic with a patient or reinforce training in real time via telehealth. Application of wound dressings, wound cleansing, troubleshooting negative pressure wound therapy devices, etc.
• Pressure Injury Prevention: Instruct caregivers on turning and repositioning, transfers, offloading techniques (heels and buttocks), nutrition, skin inspection and signs to report, moisture management, proper usage of support surfaces (cushions/mattress/heel floats).
• Infection Control: Wound care techniques, handwashing, gloves, early recognition of signs of infection to report, preventing cross-contamination, etc.
• Behavior management and modification: Offloading, keeping appointments, smoking cessation, blood glucose management, nutrition to support wound healing, elevating legs, exercise, etc.  
• For more information and resources on patient and caregiver education, see topic "Patient Education in Wound Care and Hyperbaric Oxygen Therapy"

Services Addressing Health-Related Social Needs

• For CY 2025 CMS issued a broad request for information (RFI) from the public on the newly implemented Community Health Integration (CHI) (HPCCS codes G0019, G0022), Principal Illness Navigation (PIN) (HCPCS codes G0023, G0024), Principal Illness Navigation- Peer Support (PIN-PS) (HCPCS codes G0140, G0146), and Social Determinants of Health Risk Assessment  (SDOH RA) (HCPCS code G0136) services to engage interested parties on additional policy refinements for CMS to consider in future rulemaking.

Telehealth Flexibility

Starting January 1, 2025, Medicare telehealth services will return to some pre-COVID restrictions unless Congress takes further action. This includes reapplying geographic and location limitations and narrowing the list of practitioners eligible to provide telehealth services. However, CMS aims to retain flexibility and expand telehealth access where possible.

Key Updates for CY 2025:

• Expanded Telehealth Services: CMS has added caregiver training, PrEP counseling, and safety planning interventions to the Medicare Telehealth Services List, with caregiver training services (CPT codes 97550, 97551, 97552, 96202, 96203 and HCPCS codes G0541- G0543 (GCTD1-3) and G0539-G0540 (GCTB1-2)) on a provisional basis and the other services as permanent additions.
• Suspension of Visit Limits: CMS will continue suspending frequency limits for follow-up inpatient, nursing facility visits, and critical care consultations.
• Audio-Only Option: For patients who cannot or do not wish to use video, CMS will allow two-way audio-only communications for telehealth services delivered in the home.
• Telehealth from Practice Locations: Distant site practitioners may use their practice location addresses for telehealth services provided from home, preserving location flexibility for another year.
• Virtual Supervision Flexibility: CMS is making permanent the ability for supervising physicians to provide direct supervision virtually for certain services using real-time audio and video. This includes “incident to” services and outpatient E/M visits for established patients, simplifying supervision requirements.
• CMS is specifically finalizing to make permanent that the supervising physician or practitioner may provide such virtual direct supervision
• (1) for services furnished incident to a physician or other practitioner’s professional service, when provided by auxiliary personnel employed by the billing physician or supervising practitioner and working under his or her direct supervision, and for which the underlying HCPCS code has been assigned a PC/TC indicator of “5” and services described by CPT code 99211, and
• (2) for office or other outpatient visits for the evaluation and management of an established patient who may not require the presence of a physician or other qualified healthcare professional.
• For all other services furnished incident that require the direct supervision of the physician or other supervising practitioner, CMS finalized to continue to permit direct supervision be provided through real-time audio and visual interactive telecommunications technology only through December 31, 2025.

Advanced Primary Care Management Services (APCM)

• For CY 2025, CMS has introduced new coding and payment for Advanced Primary Care Management (APCM) services under the Medicare Physician Fee Schedule. These services, represented by three new HCPCS G-codes (G0556, G0557, and G0558), aim to streamline care for patients with chronic conditions by bundling several essential primary care management services. Unlike previous codes, the new APCM codes eliminate time-based billing requirements, reducing administrative tasks for providers. Providers need to satisfy a series of requirements to be able to bill those codes.
• The three APCM levels are based on a patient’s number of chronic conditions and Medicare beneficiary status:
• Level 1 (G0556): For patients with one chronic condition.
• Level 2 (G0557): For patients with two or more chronic conditions.
• Level 3 (G0558): For patients with two or more chronic conditions who are Qualified Medicare Beneficiaries.

Supervision Policy Adjustments for Therapists in Private Practice

• Updated regulations permit general supervision of physical and occupational therapy assistants, potentially easing staffing challenges.

Drugs and Biological Products Paid Under Medicare Part B 

• For CY 2025, CMS has finalized policies for Medicare Part B payments related to single-dose or single-use package drugs, aiming to reduce waste and improve cost efficiency.
• Refund Requirement for Discarded Amounts: Drug manufacturers must provide refunds for unused portions of certain single-dose or single-use drugs. This policy, stemming from the Infrastructure Investment and Jobs Act, seeks to minimize waste and ensure fair reimbursement.
• Exclusions for Recent Drugs: Drugs covered under Part B for fewer than 18 months are excluded from the refund requirement, helping ease administrative burdens for new medications.
• JW Modifier Requirement: CMS finalized a requirement that the JW modifier must be used if a billing supplier is not administering a drug, but there are amounts discarded during the preparation process before supplying the drug to the patient.
• Skin Substitutes Excluded: Skin substitutes are excluded from the refundable drug list for 2025

Strategies for Improving Global Surgery Payment Accuracy

• For CY 2025, CMS has introduced updates to improve the accuracy of payments for 90-day global surgical packages. 
• CMS finalized the proposal to broaden the applicability of transfer of care modifier -54 for 90-day global packages as proposed. Beginning with services furnished in CY 2025, modifier -54 is required for all 90-day global surgical packages in any case when a practitioner plans to furnish only the surgical procedure portion of  the global package (including both formal and other transfers of care). CMS did not finalize any changes regarding the use of modifier -55 and modifier -56 for CY 2025. Modifiers -55 and -56 will continue to be billed exclusively in cases where there is a documented formal transfer of care.
• Modifier -54 Surgical Care Only: this modifier is appended to the relevant global package code to indicate that the proceduralist performed only the surgical procedure portion of the global package
• Modifier -55 Post-operative Management Only: this modifier is appended to the relevant global package code to indicate that the practitioner performed only the post-operative management portion of the global package.
• Modifier -56 Pre-operative Management Only: this modifier is appended to the relevant global package code to indicate that the practitioner performed only the pre-operative portion of the global package. 
• New Add-On Code for Postoperative Care (HCPCS G0559): A new code is available for post-op care provided by a different practitioner other than the one who performed the surgical procedure (or another practitioner from the same practice as the surgeon). This add-on code aims to reflect the additional time and resources involved in follow-up care by providers other than the primary surgeon.

WoundReference Resources

• HCPCS/CPT Codes and Physician Fee Schedule Commonly Utilized in Wound Care and HBOT
  
• Patient Education in Wound Care and Hyperbaric Oxygen Therapy
• Telehealth in Wound Care - Evidence and Best Practices
  
• Skin Substitutes - What's New in 2024? Preparing for a Phased Approach
• Global Surgical Transfer of Care to the Wound Clinic