Medicare Issues 2025 Final Payment Policies for Outpatient Services

Payment Rates

Conversion Factor

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. For 2025, CMS estimates that the CF will be $32.35, representing a 2.83% decrease from the $33.29 CF for 2024. Although CMS included a 0.02% positive budget neutrality adjustment, the decrease in the CF is mostly due to expiration of the temporary 2.93% positive adjustment that Congress implemented to temporarily mitigate significant payment cuts in 2024.

CMS also provides a regulatory impact analysis (RIA), which estimates cumulative payment changes for providers in addition to the cut to the CF. For 2025, it's estimated that audiologists and SLPs will see a cumulative 0% additional change in payments based on policy changes. However, cumulative payment changes experienced by individual clinicians or practices will vary because actual payment depends on several factors, including the clinician's location and the specific procedure codes billed.

ASHA will share final 2025 national payment rates for audiology and speech-language pathology services in its full MPFS analysis.

Additional Payment Cuts

Medicare providers face other cuts known as sequestration (2% reduction) and statutory "Pay-As-You-Go," or PAYGO (4% reduction), due to laws that control federal spending. Although these specific cuts aren't addressed in the MPFS, they could result in a total cut of almost 9% to overall Medicare payments when added to the CF reduction.

Congress has acted each year by passing legislation that reduced or eliminated some of these additional cuts and will need to do so again for 2025 payments.

Next Steps for ASHA: Annual reductions hurt our members and their patients, which is why we have strongly advocated against Medicare Part B payment cuts since they were first set to occur in 2021. Due to federal budget concerns and competing congressional priorities, there's no guarantee Congress will address the 2025 cuts. Audiologists and SLPs should prepare for the possibility that the payment cuts will go into effect on January 1, 2025.

This vicious cycle requires all of us to lobby Congress to intervene and to stop the payment cuts. Congressional intervention has helped soften the blow of the cuts each year, but it's not enough. Medicare providers will continue to face payment instability unless Congress reforms the Medicare payment system. ASHA is fully committed to continuing advocacy and collaboration with members of Congress, CMS, key decision makers, and allied professional organizations (whose providers are also impacted) to find short- and long-term solutions to address Medicare payment issues-including supporting H.R. 10073, the Medicare Patient Access and Practice Stabilization Act.

What You Can Do: ASHA members can take action by urging their members of Congress to fully address the multiple sources of payment reductions, including by passing H.R. 10073, which would provide an annual inflationary payment update based on the Medicare Economic Index. Ask your colleagues and friends to do the same to support this important legislation.

Coding Updates

There are no new or revised procedure codes directly related to audiology services for 2025. SLPs should be aware of updates to policies around the existing CTS codes and new CTS services for which they are eligible to be paid.

Caregiver Training

Beginning in 2024, SLPs have been able to report CTS without the patient present when provided under an established, individualized, and patient-centered plan of care to facilitate a patient's functional performance. The final rule includes refinements to the existing CTS policies.

Patient Consent

One criterion for CTS billing requires the SLP to receive consent from the patient (or their representative) to provide caregiver training without the patient present. However, CMS does not dictate the form or manner of obtaining and documenting this consent. The flexibility of this policy is important to ensure clinicians can obtain consent in a way that reduces administrative burden and maintains access to care for patients. In the final rule, CMS includes important guidance to allow verbal consent from the patient or the patient's representative. Verbal consent must be documented somewhere in the patient's medical record, but CMS maintains the flexibility to allow clinicians and facilities to determine their own protocols for obtaining and documenting consent.

Telehealth List

CTS has been added to the authorized telehealth services list for 2025 on a provisional basis.

New Caregiver Training G-Codes for Primary Care Services

CMS finalized a new set of Medicare-specific G-codes for caregiver training without the patient present in direct care strategies and techniques to support care for patients with ongoing conditions or illness and to reduce complications. These are similar to the existing CTS codes available for SLPs and valued at the same rate.

In its comments [PDF], ASHA asked how the new Medicare-specific G-codes for caregiver training may overlap with services described in the CTS codes used by SLPs. In response, CMS is designating direct care CTS as a "sometimes therapy" service when personally furnished by SLPs. This means that SLPs can report these codes when the type of caregiver training provided is not intended to facilitate functional performance of the patient but to support care of the patient by preventing adverse health events such as, but not limited to, infections and monitoring for potential complications. SLPs will continue to use CPT codes 97550, 97551, and 97552 when caregiver training is directly related to functional performance of the patient.

The following new codes are effective beginning January 1, 2025. These G-codes are Medicare-specific. Other payers may add them to their fee schedules, but it is important for SLPs to check with them directly before billing these codes.

Code	Descriptor
G0541	Caregiver training in direct care strategies and techniques to support care for patients with ongoing conditions 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 ongoing conditions 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

SLPs should keep in mind that services reported using these G-codes are distinctly different from CPT codes 97550-97552, which focus on caregiver training to support a patient's functional performance. These G-codes should only be reported for those times when an SLP may be providing training without the patient present to provide caregiver(s) with strategies to help reduce complications or prevent adverse health events. This training should not be associated with goals related to a patient's functional performance. In addition, the services described by the new G-codes must be incorporated into the patient's plan of care. If a patient is already under a therapy plan of care, this may be as simple as updating and recertifying the plan of care. However, CMS hasn't provided guidance in those instances when a patient isn't currently under a therapy plan of care but has been referred to the SLP for services that could be billed under the new G-codes.

Below are examples of situations when SLPs provide medically necessary caregiver training services that could fall under these new caregiver training codes.

Example 1: Wound, stomal, and tracheoesophageal puncture (TEP) care in laryngectomy patients: Improper stomal and TEP care can lead to significant negative health outcomes. In these situations, caregivers play a vital role in ensuring proper stomal and TEP care by providing cleaning, humidifying, and monitoring of the sites for granulation tissue, fistula, and leakage in order to prevent complications. Caregivers of these patients may require extensive training on infection control and prevention, stomal and wound care, functioning of a TEP prosthesis, detecting signs of a malfunctioning prosthesis, and the need for a new prosthesis. This training, which is not directly related to the patient's functional performance, could be completed by SLPs and billed under these Medicare-specific G-codes.

Example 2: Pain and lymphedema management in head and neck cancer patients: Lymphedema and pain are devastating conditions that frequently follow surgery and/or radiation treatment for head and neck cancer. Head and neck lymphedema lead to other complications such as infections or trismus. These patients often rely on their caregivers to monitor lymphedema and prevent complications, such as the need for tracheostomy. Caregiver training that SLPs may provide includes supporting lifestyle modifications, detecting worsening lymphedema, and preventing infection, which could be billed under these new codes.

Next Steps for ASHA: ASHA will seek further clarification from CMS on the use of these new G-codes by SLPs as "sometime therapy" codes and how they should be reflected in a plan of care. We will update our members as this guidance becomes available.

Caregiver-Focused Health Risk Assessment Completed by SLPs

In ASHA's comments [PDF], we requested SLPs be paid for the services described by CPT code 96161 (administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument) to assess a caregiver's skill and knowledge. In the final rule, CMS did not directly address the use of this code by SLPs and noted that this service may be billed by practitioners. Medicare classifies SLPs as suppliers and not practitioners, so SLPs aren't currently eligible to bill for these services. However, CMS states that a caregiver is not required to have a caregiver-focused health risk assessment to participate in caregiver training services.

Next Steps for ASHA: ASHA will continue to work with CMS to identify opportunities for SLPs to access the full range of CPT codes available to support caregiver training.

Telehealth

ASHA Request to Add Services to the Authorized Telehealth List

The structure of the Medicare telehealth benefit is split between Congress and CMS. This process is only applicable to traditional Medicare telehealth coverage. State Medicaid programs, private insurers, and Medicare Advantage plans will set their own telehealth coverage policies. Audiologists and SLPs should check with these payers directly to determine their coverage policies.

Congress	CMS
Determines the clinical specialties who are eligible telehealth providers	Determines which services are covered telehealth benefits

CMS has an established process for reviewing requests from the public to add Current Procedural Terminology (CPT®) codes to the authorized telehealth services list on a permanent basis. This process requires that a letter, outlining the codes being requested for addition to the list along with research and evidence supporting their inclusion, be submitted to the Agency by February 10 of each year. CMS staff members review these requests and outline their determinations in each year's proposed rule.

ASHA submitted a request [PDF] in February 2024 requesting that CMS permanently add audiology and speech-language pathology CPT codes that have been temporarily authorized telehealth services since March 2021. While audiologists and SLPs may not be authorized telehealth providers in 2025 without congressional action, ASHA maintains that the development of a robust telehealth benefit is critically important to ensure continuity of care for Medicare beneficiaries by ensuring there is a benefit in place that can be more easily implemented when these clinicians are added.

While CMS did not make a specific proposal to maintain these codes on the telehealth services list on a provisional basis, it "clarified" in the final rule that it will keep any CPT codes that currently have provisional approval on the authorized telehealth services list in 2025. But it will not add these services to the telehealth services list permanently until it has performed a "comprehensive analysis" of these services.

Next Steps for ASHA: ASHA will continue to advocate for permanent coverage of our members' telehealth services with both CMS and Congress. We will share information about the status of Medicare telehealth coverage as it becomes available. If Congress does not pass legislation extending Medicare telehealth coverage in 2025, ASHA members may be able to enter into private pay arrangements with the patients as described on our website.

What You Can Do: Visit ASHA's Take Action site to urge your members of Congress to advocate for permanent telehealth coverage under Medicare.

Updated Telehealth Policies

ASHA is pleased to see that CMS finalized several telehealth-related changes for 2025. CMS will continue to allow clinicians who are providing telehealth services to Medicare beneficiaries from their homes to use their business address on claims to protect their privacy and security. CMS will also allow two-way, real-time audio-only communication technology to qualify as a telehealth service furnished to a beneficiary in their home if the clinician is technically capable of using audio and video equipment that enables two-way, real-time interactive communication, but the patient is not capable of, or does not consent to, the use of video technology. To use this flexibility, clinicians in outpatient settings will be required to report modifier "93" (audio-only synchronous telemedicine service) on the claim to verify that these conditions have been met.

Updates to the Therapy Plan of Care Requirements

For 2025, CMS finalized amendments to the certification of the plan of care regulations to reduce the administrative burden for therapists and physician/nonphysician practitioners (NPPs). These changes provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification. This exception applies in cases where the patient's medical record includes a signed and dated written order or referral from the patient's physician/NPP and evidence that the therapist has transmitted the treatment plan to the physician/NPP within 30 days of the initial evaluation (e.g., fax confirmation, copies of emails or electronic health record transmission, snail mail delivery confirmations).

Supervision of Therapy Assistants

For 2025, CMS finalized a regulatory change to allow for general supervision of physical therapist assistants and occupational therapy assistants by physical therapists in private practice and occupational therapists in private practice for all applicable physical and occupational therapy services. Speech-language pathology assistants (SLPAs) are not currently recognized under federal law as qualified providers, so their services are not covered. Should we secure coverage for assistants in the future, we will need to confirm this policy applies equally to SLPAs.

Telesupervision of "Incident To" Services

SLPs, physical therapists, and occupational therapists are allowed to provide services "incident to" a physician with direct supervision. "Incident to" coverage policies state that the services of the therapist would be billed under the National Provider Identifier (NPI) of the supervising physician. Direct supervision is typically defined as "in the office suite and immediately available to help if needed." This definition was relaxed during the COVID-19 public health emergency to allow for telesupervision―supervision via real-time audio and visual interactive telecommunications.

CMS will continue to allow telesupervision through 2025 for physical and occupational therapy and speech-language pathology services. In addition, it will allow for telesupervision on a permanent basis for any CPT code with a professional and technical component (PC/TC) status indicator of "5" 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). CPT codes primarily billed by SLPs do not have a PC/TC status indicator of "5," which means that unless CMS makes additional changes through rulemaking for 2026, SLPs will not be eligible to be telesupervised after 2025.

CMS also finalized a change that would allow it to add services to the telesupervision list at any time if these services meet specified criteria, including the services that are inherently lower risk. This includes services that 1) do not ordinarily require the presence of the billing practitioner, 2) do not require direction by the supervising practitioner to the same degree as other services furnished under direct supervision, and 3) are not services typically performed directly by the supervising practitioner.

While ASHA believes speech-language pathology services meet this criteria for permanent telesupervision and urged CMS to finalize telesupervision on a permanent basis, CMS elected not to do so. Therefore, telesupervision for therapy services provided "incident to" can continue for 2025 but will revert to the "in-person" standard in 2026 without any additional changes.

Quality Payment Program (QPP)

The QPP transitions Medicare payments away from a volume-based fee-for-service payment to a more value-based system of quality and outcomes-based reimbursement. The program includes Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

Alternative Payment Models (APMs)

Only a small percentage of audiologists and SLPs participate in the APM track. These clinicians typically work for larger health care systems and have the support of finance and administration departments to manage the complexity of such models. CMS added new quality measures and will reward efforts to improve health equity in the 2025 final rule. Audiologists and SLPs working for organizations participating in APMs can help their organizations earn incentive payments by engaging in quality improvement efforts.

APMs are designed to improve the patient experience by encouraging collaboration between providers, improving quality of care, and making services more affordable. APM participants receive payments that reward them for the value of-rather than the volume of-services provided. Value, in this context, refers to outcomes of the intervention as related to cost. Accountable Care Organizations (ACOs) are one type of APM that take system-wide responsibility for the care of an individual across all their health care needs.

To incentivize ACOs to serve more beneficiaries from underserved communities, CMS finalized a Health Equity Benchmark Adjustment (HEBA) to be applied based on the number of beneficiaries they serve who are dually eligible or enrolled in the Medicare Part D Low-Income Subsidy.

Beginning in 2025, CMS will also require Shared Savings Program ACOs to report the APM Performance Pathway (APP) Plus Quality Measure Set. This measure set will be an optional measure set for MIPS-eligible clinicians, groups, and APM entities that participate in a MIPS APM. This would include the six measures currently in the APP quality measure set and would incrementally incorporate the remaining five Adult Universal Foundation quality measures by the 2028 performance period/2030 payment year with preference for reporting electronically through electronic clinical quality measures (eCQMs).

New measures in the APP Plus Quality Measure Set for Shared Savings Program ACOs that could involve audiologists and SLPs include:

• #479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS-Eligible Clinician Groups Beginning in PY 2025 (claims-based measure)
• #484 Clinician and Clinician Group Risk-Standardized Hospital Admission Rates for Patients With Multiple Chronic Conditions Beginning PY 2026 (claims-based measure)
• #487 Screening for Social Drivers of Health Beginning in PY 2028.

CMS also finalized a new calculation methodology to account for the impact of improper payments when reopening a payment determination to recoup payments it believes were not properly earned.

Learn more about APMs and value-based care on ASHA's website.

Download additional details about the QPP from CMS here [PDF].

Merit-Based Incentive Payment System (MIPS)

CMS continues to focus on the transition from MIPS to MIPS Value Pathways (MVPs) by adopting new MVPs related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. They are consolidating the two neurology-focused MVPs into a single neurology MVP. They also requested information on challenges clinicians may face in adopting MVPs, data reporting for public health, and the use of Patient-Reported Outcome Measures (PROMs), Patient-Reported Outcome Performance Measures (PRO-PMs), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the MIPS Survey. ASHA members can participate in MVPs as members of larger health care systems but not as individuals or as private practices because the current structure of MVPs does not allow for effective nonphysician participation.

Of the four performance categories under MIPS, audiologists and SLPs are required to report on quality, improving interoperability, and improvement activities, but not cost. CMS revises its cost measure scoring methodology to assess clinician cost of care more appropriately in relation to national averages.

Additional information on MIPS is available on ASHA's website.

Audiology Measures

CMS does not add any measures to the audiology specialty measure set but it does modify the measure specifications for Measure #130. This measure was amended from "Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter" to "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."

Speech-Language Pathology Measures

We are pleased that CMS is adding five measures to the speech-language pathology specialty measure set for the 2025 performance/2027 payment year in response to a request from ASHA last year [PDF]. Those measures include:

1. Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
2. Dementia: Functional Status Assessment: Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.
3. Dementia: Safety Concern Screening and Follow-Up for Patients With Dementia: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concern screening in two domains of risk: (1) dangerousness to self or others and (2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.
4. Dementia: Education and Support of Caregivers for Patients With Dementia: Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.
5. Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences: Percentage of patients diagnosed with ALS who were offered assistance in planning for end-of-life issues (e.g., advance directives, invasive ventilation, lawful physician-hastened death, hospice) or whose existing end-of-life plan was reviewed or updated at least once annually or more frequency as clinically indicated (i.e., rapid progression).

Clinicians continue to be excluded from mandatory MIPS participation if they have: 1) allowed charges for covered professional services less than or equal to $90,000, 2) furnished covered professional services to 200 or fewer Medicare Part B-enrolled individuals, or 3) furnished 200 or fewer covered professional services to Medicare Part B-enrolled individuals. Given these standards, ASHA estimates that less than 1% of its members are subject to MIPS.

Social Determinants of Health (SDOH)

SDOH describes "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks."

While CMS requested information on several new health-related social needs services, including Social Determinants of Health Risk Assessment (SDOH RA) (HCPCS code G0136) currently used by primary care physicians, CMS did not finalize ASHA's request to extend use of this code to audiologists and SLPs.

CMS also requested information regarding the use of Z codes (ICD-10-CM codes Z55-Z65), which are used to document an individual's SDOH data and come in nine broad categories of SDOH known to affect patients' health outcomes (e.g., housing, psychosocial, literacy). ASHA supports the use of Z codes to accurately collect SDOH information to ensure patient needs are being met when these factors impact their experience and outcomes of care. In addition, this information could help ensure payment adequately considers the impact of SDOH on the cost of care.

Find out more about SDOH and Z codes [PDF] on ASHA's website.

Medicare Targeted Manual Medical Review

CMS notes that the Bipartisan Budget Act of 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review process first applied in 2015. Therefore, Medicare beneficiaries can continue to receive medically necessary treatment with no arbitrary payment limitations. However, clinicians must append modifier "KX" when medically necessary services reach a monetary threshold, which changes annually. For 2025, CMS estimates the KX modifier threshold will be $2,410 for physical therapy and speech-language pathology services combined. This represents an $80 increase from the 2024 threshold amount of $2,330. Find more information regarding the permanent repeal of the therapy cap and the current targeted medical review process on ASHA's website.

What's next?

The final rule will be effective for services provided on or after January 1, 2025. We will keep members informed on additional developments.

ASHA Resources

• 2024 Medicare outpatient payment rates
• Take Action to stop Medicare cuts
• Take Action to make telehealth access permanent for Medicare beneficiaries
• Medicare resources
• ASHA Comments on the 2025 Fee Schedule Proposed Rule [PDF]

Questions?

Please contact ASHA's health care and education policy team at [email protected].