Reprinted from NASW Tips & Tools for Social Workers
NASW Practice Team
Mirean Coleman, LICSW – Director of Clinical Practice
April Ferguson, LCSW-C – Senior Practice Associate
Chris Herman, LICSW – Senior Practice Associate
Denise Johnson, LCSW-C – Senior Practice Associate
Makeba Royall, LCSW – Senior Practice Associate
January 2025
In late 2024 the Centers for Medicare and Medicaid Services (CMS) issued the 2025 Medicare Physician Fee Schedule (PFS).* This 1,348-page rule updates policies and payments for clinical social workers (CSWs) and other Medicare providers; these changes, in turn, affect health coverage for beneficiaries. Changes related to payments and other Medicare Part B policies addressed in the PFS take effect on or after January 1, 2025.
Background
Since 1992, the Medicare PFS has been used to determine payments for services provided both by CSWs who are Medicare providers and for other Medicare providers who work in various settings, including offices, hospitals, ambulatory care centers, and behavioral health. Payment rates for each type of provider are determined by applying relative value units (RVUs) for work, practice expenses, and malpractice costs to each service; adjusting for geographic cost variations; and incorporating statutory updates.
The PFS is specific to Medicare. Although Medicare's policies may influence or serve as a reference for other payers, they do not automatically apply to Medicaid or private health insurance plans. CSWs should contact third-party payers with whom they are credentialed for information related to billing and reimbursement.
This publication summarizes the 2025 Medicare PFS final rule and its implications for social work practice.
Determination of Payment
Conversion Factor
The conversion factor determines payment for psychiatric and other services by multiplying it with the RVU assigned to specialties such as CSWs. A decrease in the conversion factor leads to an average reduction in reimbursement for CSWs (which is also influenced by factors such as the economic index and geographic location). This conversion reduction is necessary to maintain Medicare budget neutrality, ensuring payment rates do not alter overall Medicare spending.
In calendar year (CY) 2025, payment rates under the PFS are 2.93% lower than they were in CY 2024. This reduction reflects the end of a temporary 2.93% increase for 2024, a required 0% overall update, and a small 0.02% adjustment for changes in RVUs.
CY 2025 PFS Impact Discussion
CMS previously finalized an increase in the valuation for timed behavioral health services under the PFS, resulting in an increase of payment for psychotherapy codes over a four-year period. NASW appreciates this initiative to improve work values for behavioral health services.
Payment for Medicare Telehealth Services
Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations
This provision addresses the frequency of evaluation and management (E/M) services provided by physicians and nonphysician practitioners—such as physician assistants, nurse practitioners, and clinical nurse specialists—to residents of skilled nursing facilities (SNFs). Before the COVID-19 pandemic began, these nonphysician practitioners were allowed to provide services using telehealth up to once every 14 days after an initial in-person visit by the practitioner. (These “subsequent care services” are reflected in Current Procedural Terminology [CPT®] codes 99307 through 99310.) During the height of the pandemic, CMS removed this 14-day frequency limitation on Medicare telehealth subsequent care services to promote continuity of service provision. The agency has continued to suspend the frequency limitation since May 2023, when the COVID-19 public health emergency (PHE) ended.
In the current final rule, CMS finalized its proposal to suspend the telehealth frequency limitation for subsequent care services provided to SNF residents throughout CY 2025. NASW had objected to this proposal in its comments on the proposed rule, asserting that “in-person, facility-based visits by physicians and nonphysician practitioners are essential to quality of life and quality of care for residents, who have complex health conditions and whose self-advocacy abilities are often limited.” CMS acknowledged these concerns in the final rule, stating:
We are continuing to consider what changes we should be making to how telehealth services are paid under Medicare in light of the way practice patterns may have changed following the PHE for COVID–19. … We believe that continuing to suspend these frequency limitations on a temporary basis for CY 2025 will allow us more time to evaluate patient safety while preserving access in a way that is not disruptive to practice patterns that were established during and after the PHE. We appreciate the information regarding both patient safety concerns and concerns regarding supporting healthcare access. We expect to address these concerns in future rulemaking. (p. 97759)
Audio-Only Communication Technology to Meet the Definition of “Telecommunications System”
As of January 1, 2025, CMS allows two-way, real-time, audio-only communication for Medicare telehealth services provided to a beneficiary in their home. This applies if the distant site practitioner can use interactive telecommunications (that is, a two-way, real-time audio–video system), but the beneficiary cannot or does not consent to using video technology. NASW supports this revision because it enhances inclusivity and accessibility in telehealth services by reducing technological barriers, thereby promoting greater use of telehealth and improving overall health care access. When billing Medicare for telehealth services using two-way, real-time, audio-only communication, social workers must include either CPT® modifier "93" or Medicare modifier "FQ" (or both, if applicable) in their claims.
CMS has limited authority to extend most Medicare telehealth policies. Without Congressional action, major Medicare telehealth waivers were scheduled to expire on December 31, 2024, reverting to pre–COVID-19 policies. However, on January 6, 2025, Congress approved the American Relief Act, 2025 (Pub. L. 118–158), which extended the telehealth waivers to March 31, 2025. As of April 1, 2025, most Medicare telehealth services will require beneficiaries to be in a medical facility in a rural area—except for behavioral health telehealth services, which can continue to be provided in the beneficiary’s home. Moreover, the law delays the in-person requirement for telemental health services through March 31, 2025.
NASW is pleased that CMS has permitted the continuation of telehealth services for behavioral health. The association has advocated for the continued extension of these flexibilities to support increased access to care.
Distant Site Requirements
CMS continues to allow distant site practitioners to use their enrolled practice locations, rather than their home addresses, when providing telehealth services from home. NASW supports the continuation of this requirement, which helps protect the privacy and safety of telehealth practitioners.
Direct Supervision and Audio–Video Communications Technology
CMS finalized a rule to allow virtual direct supervision via real-time, two-way, audio–video telecommunications for certain services. This permanent change applies to the following services:
services provided incident to a physician's or practitioner's professional service by auxiliary personnel
office or outpatient visits for established patients who do not require the presence of a physician or other qualified health care professional
For other services requiring direct supervision, virtual supervision is permitted through December 31, 2025. NASW supports CMS’s decision to extend the definition of direct supervision to include real-time audio–video telecommunication. In its comments on the PFS proposed rule for CY 2025, NASW had also urged CMS to ensure that virtual supervision maintains the same oversight as in-person supervision and to implement safeguards against potential fraud and abuse, ensuring compliance with requirements of both the Health Insurance Portability and Accountability Act (HIPAA, Pub. L. 104–191) and Medicare.
Telehealth Originating Site Facility Fee Payment
As a result of the PFS final rule for CY 2025, claims using the Place of Service (POS) code “10” continue to be reimbursed at the higher nonfacility rate. The CY 2024 PFS final rule established that, starting in CY 2024, telehealth services performed in a beneficiary’s home and billed with POS code 10 would be reimbursed at the nonfacility PFS rate. The CY 2025 final rule extended this policy to CY 2025 and subsequent years. NASW appreciates CMS’s decision to maintain reimbursement at the higher nonfacility rate for telehealth services performed in the homes of Medicare beneficiaries.
Valuation of Specific Codes
Caregiving Training Services
Caregiver training services (CTS) help family caregivers (defined broadly by CMS) support beneficiaries with certain physical or behavioral health conditions in carrying out a beneficiary’s individualized plan of care. Of greatest pertinence to the social work profession, the CY 2025 PFS final rule clarified that CSWs may furnish independently and may bill Medicare directly for CTS when these services are integral to a beneficiary’s plan of care for a mental health condition. The following codes reflect CTS:
CPT® code 96202: multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional without the patient present; face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes
CPT® code 96203: each additional 15 minutes of CTS described by CPT® code 96202; to be used in conjunction with CPT® code 96203
Healthcare Common Procedure Coding System (HCPCS) code G0539: individual caregiver training in behavior management/modification for caregiver(s) of a patient with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face; initial 30 minutes)
HCPCS code G0540: each additional 15 minutes of CTS described by HCPCS code G0539; to be used in conjunction with HCPCS code G0539
Moreover, CMS has added these services to Medicare Telehealth List for CY 2025 on a provisional basis.
The ability of CSWs to provide CTS independently and to bill Medicare directly for CTS corresponds with NASW’s advocacy regarding the proposed PFS rules for CY 2024 and CY 2025. A separate Tips & Tools for Social Workers addressing CTS in greater detail is forthcoming.
Services Addressing Health-Related Social Needs (HRSNs)
In the CY 2025 proposed rule, CMS issued a broad request for information (RFI) on health equity codes for Community Health Integration (CHI), Principal Illness Navigation (PIN), and Social Determinants of Health (SDOH) Risk Assessment. CMS received many comments that they will consider in future rulemaking, and the health equity services are continuing as described in the CY 2024 Final PFS.
CMS recognizes the importance of CSWs who help to address unmet HRSNs. CMS clarified that CSWs can serve as auxiliary personnel to deliver CHI, PIN, and SDOH Risk Assessment services. In addition, CMS has stated that SDOH Risk Assessment may be provided during a behavioral health visit. NASW is still seeking confirmation that CSWs may furnish and bill Medicare for SDOH Risk Assessment when providing a behavioral health visit.
Furthermore, NASW had requested clarification regarding the ability of social workers at other levels of practice to serve as auxiliary personnel in health care and community settings. Social workers at the bachelor’s and master’s levels work in community-based organizations and have relevant training to support individuals with complex health and social needs. CMS confirmed that social workers may perform CHI and PIN services as auxiliary personnel “so long as they meet the requirements to provide all elements of the service included in the code, consistent with the definition of auxiliary personnel at § 410.26(a)(1).”
In the CY 2024 PFS final rule, CMS indicated that CSWs may not directly bill Medicare for CHI or PIN services that are provided by other auxiliary personnel. NASW will continue its advocacy for CSWs to bill Medicare directly for health equity services.
Advanced Primary Care Management
NASW expressed support for enhancing services through primary care in the Advanced Primary Care Management (APCM) model. The APCM model includes care management services to support beneficiaries with complex and chronic conditions with billing codes that are not time based.
NASW encourages primary care practices to include social work practitioners on staff to serve the range of patients that require varied levels of support. NASW also appreciates the clarification that auxiliary personnel, including social workers, can provide these services within a team.
In the proposed rule, CMS had outlined other care management services that may duplicate APCM. At this time, CMS is not finalizing concurrent billing restrictions. However, a provider who furnishes APCM cannot bill Medicare for APCM and Chronic Care Management (CCM), Principal Care Management (PCM), or Transitional Care Management (TCM) simultaneously. CMS states, and NASW agrees, that additional services for particular health care needs can complement APCM, including behavioral health integration (BHI) and health equity services such as SDOH Risk Assessment, CHI, and PIN, when the requirements for each service are met.
Advancing Access to Behavioral Health Services
Safety Planning Interventions (SPI)
CMS proposed establishment of separate coding and payment for SPI, which support beneficiaries experiencing a suicidal or overdose crisis. In its comments on the proposed rule, NASW supported the proposal. NASW also recommended that CMS consider billing in multiple 20-minute increments, to a maximum of 120 minutes, to capture accurately the amount of time a practitioner may spend providing SPI.
The final rule stated that CMS had decided to establish a stand-alone code, HCPCS code G0560, for SPI. To use HCPCS code G0560, the service must be provided directly by the billing practitioner, such as a CSW.
CMS also stated that SPI can be billed in 20-minute increments. NASW is pleased that CMS considered the association’s comments and supported the importance of having adequate time to create a safety plan.
Post Discharge Telephonic Follow-up Contact Intervention (FCI)
In the proposed rule, CMS proposed to create a monthly billing code to describe the specific protocols involved in furnishing FCI that are performed in conjunction with a discharge from the emergency department for a crisis encounter, as a bundled service describing four calls in a month, each lasting between 10 and 20 minutes. The treating practitioner must obtain the beneficiary’s written consent before furnishing the post discharge FCI and must document that consent in the clinical record. NASW supported this proposal and the establishment of the billing code HCPCS G0544 for post discharge FCI.
Rather than establishing a time limit for post discharge FCI code usage, as it did for SPI, CMS has indicated that the code can be billed and reimbursed as long as the service is medically reasonable and necessary. However, CSWs must complete at least one real-time telephone interaction with the beneficiary to bill for HCPCS code G0544, and unsuccessful attempts do not qualify as an attempt. CMS considered feedback from the commenters related to obtaining consent and has indicated that consent can be obtained either before or during the initial phone call. NASW supported this proposal.
Digital Mental Health Treatment (DMHT)
To support access to psychotherapy, CMS, in collaboration with the Federal Drug Administration (FDA), finalized Medicare payment for digital mental health treatment devices. A DMHT device refers to any FDA-approved software device used to treat or alleviate mental health conditions in conjunction with ongoing substance use disorder treatment. Three new codes have been developed for CSWs to bill for DMHT services: G0552 for purchasing the device and initial education/onboarding, G0553 for the first 20 minutes of monthly treatment management, and G0554 for additional 20 minutes of monthly treatment management.
NASW supported CMS’s proposal to create new HCPCS codes for DMHT devices that are safe and effective. The association emphasized that DMHT should complement traditional therapies under the clinician’s guidance. NASW also highlighted the need to consider patient suitability, access to technology, and the importance of maintaining the therapeutic relationship.
Interprofessional Consultation Billed by Practitioners Authorized by Statute to Treat Behavioral Health Conditions
CMS proposed new codes that would allow clinical psychologists (CPs), CSWs, marriage and family therapists (MFTs), and mental health counselors (MHCs) to bill for interprofessional consultations with other practitioners whose practice is similarly limited, as well as with physicians and practitioners who can bill Medicare for E/M services and would use the current CPT® codes to bill for interpersonal consultations. NASW strongly supported CMS’s proposal of new codes that would allow for interpersonal consultations with other practitioners. The association was also in favor of obtaining the beneficiary’s consent before participating in such interpersonal consultations.
In the final rule, CMS established HCPCS codes G0546 through G0551 for practitioners in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness. Such practitioners include CPs, CSWs, MFTs, and MHCs. Practitioners who furnish interprofessional consultations do not need to be based within the same organization. However, the beneficiary’s consent is required before the consultation begins, and that consent must be documented in the medical record. CMS indicated that such consent was necessary for two reasons: (1) The interprofessional consultation is provided outside of the patient’s presence, and (2) patients may be responsible for cost sharing for interprofessional consultation (in addition to the other service being provided by the practitioner). NASW supported this requirement.
Payment for Dental Services Inextricably Linked to Other Covered Services
Federal statute prohibits Medicare from paying for routine dental services. Since 2023, CMS has allowed Medicare coverage of dental services when they are inextricably linked to, and substantially related and integral to the clinical success of, certain other covered services or procedures. For example, dental exams and medically necessary diagnostic and treatment services may be covered as part of a comprehensive work-up before an organ transplant.
Among the oral health proposals finalized by CMS in the CY 2025 rule are two provisions that had been supported by NASW:
Medicare coverage of a dental or oral examination performed as part of a comprehensive work-up in either the inpatient or outpatient setting before the initiation of Medicare-covered dialysis services for end-stage renal disease (ESRD); CMS modified this provision to include coverage of such an examination contemporaneously with Medicare-covered dialysis services to treat ESRD
Medicare coverage of medically necessary diagnostic and treatment services to eliminate an oral or dental infection before, or contemporaneously with, Medicare-covered dialysis services for ESRD
CMS declined to extend such coverage for people in earlier stages of chronic kidney disease (a topic regarding which NASW had not commented).
In the proposed rule, CMS had sought clinical evidence demonstrating the integral connection between dental services and three types of conditions: (a) systemic autoimmune disease requiring immunosuppressive therapies, (b) sickle cell anemia), and (c) hemophilia. NASW expressed its general support for CMS’s explorations of these connections. After reviewing evidence submitted by various commenters, CMS concluded that sufficient clinical evidence of an inextricable link between dental services and a covered medical service for the three types of conditions does not exist at this time. Thus, Medicare does not cover dental services associated with these conditions in CY 2025; however, CMS will continue to explore these topics in future rulemaking. Similarly, in the proposed rule for CY 2025, CMS requested comments regarding oral appliances to treat obstructive sleep apnea. In the final rule, CMS acknowledged the comments without responding to them, stating that the issue may be addressed in future rulemaking.
Rural Health Clinics and Federally Qualified Health Centers
Telecommunication Services in RHCs and FQHCs
CMS has finalized policies to allow continued flexibility in telehealth services provided by rural health clinics (RHCs) and federally qualified health centers (FQHCs). Direct supervision via real-time interactive audio–video telecommunications (excluding audio-only communication) remain permissible through December 31, 2025, and the definition of “immediate availability” has been extended to include such technology. Additionally, Medicare payment for non–behavioral health visits (also described by CMS as “medical visit services”) conducted via telecommunications technology continues temporarily under existing methodologies that had been mandated by statute through December 31, 2024. According to the CY 2025 PFS final rule, RHCs and FQHCs can use HCPCS code G2025 to bill for medical visit services provided via telecommunications technology (including audio-only technology), through December 31, 2025. During CY 2025, the payments for these services are calculated based on the average amount of all PFS telehealth services, weighted by service volume.
NASW appreciates CMS for continuing the flexibility for direct supervision via telehealth within RHCs and FQHCs. The associations hopes similar flexibilities will be extended to medical visit services in the future.
In-Person Visit Requirements for Remote Mental Health Services Furnished by RHCs and FQHCs
CMS has delayed until January 1, 2026, the in-person visit requirement for mental health services provided by RHCs and FQHCs via telecommunication technology to beneficiaries in their homes. NASW supports CMS’s decision to maintain home-based mental health services furnished by RHCs and FQHCs. These services promote timely and effective care, especially for remote or underserved areas.
Intensive Outpatient Program (IOP) Services in RHCs and FQHCs
CMS is establishing a new payment rate for instances in which RHCs and FQHCs provide four or more IOP services per day, exceeding the existing rate for up to three services. This rate for four or more IOP services per day matches the rate for hospital outpatient departments and will be updated annually. NASW supports CMS’s establishment of the new payment rate, which can help promote consistency in care.
Care Coordination Services in RHCs and FQHCs
CMS has finalized changes to how care coordination services are reported in RHCs and FQHCs to align payments more closely with other entities. As of January 1, 2025, RHCs and FQHCs may report individual CPT® and HCPCS codes for care coordination services instead of the single HCPCS code G0511. The goals of this change are to improve payment transparency, enabling beneficiaries to understand better the services they receive, and payment accuracy. CMS is providing a six-month transition period (until at least July 1, 2025), to update billing systems. Additionally, payments to RHCs and FQHCs are now being made at national, nonfacility PFS rates and will be updated annually.
In its comments on the proposed rule, NASW supported CMS’s proposals to classify care coordination services provided by RHCs and FQHCs more clearly and consistently. The association affirmed the importance of distinguishing separately payable services and those included in visit payments. Additionally, NASW agreed with CMS that a streamlined policy and subregulatory guidance for updating these codes would enhance clarity and efficiency.
RHC and FQHC Conditions for Certification and Conditions for Coverage (CfCs)
RHCs and FQHCs operate under specific Conditions for Certification and Conditions for Coverage to ensure patient safety and qualify for Medicare and Medicaid participation. Established by the Rural Health Clinic Services Act of 1977 (Pub. L. 95–210), Medicare-certified RHCs deliver crucial care to underserved communities and currently number more than 5,400. These facilities are designed to meet the unique health care needs of rural areas while maintaining high standards of care.
CMS has finalized changes to the RHC CfCs to increase flexibility, reduce provider burden, and improve beneficiary access. RHCs are now explicitly required to provide primary care services, thereby aligning with statutory intent and preserving access to care in their communities. NASW supported CMS’s proposed updates to clarify requirements and reduce burdens, including the explicit need for RHCs to offer primary care services while allowing greater flexibility to provide specialty services.
The final rule also addressed mental health services within RHCs, emphasizing (to promote alignment with statutory requirements) that RHCs must not function primarily as agencies or facilities for treatment of mental diseases. Public feedback called for careful terminology and definitions to decrease stigmatization and to promote integrated behavioral health care. CMS withdrew its proposal in response to this feedback.
As noted previously in this publication, CMS has delayed the requirement for in-person visits for mental health services provided by FQHCs (which number almost 12,000) and RHCs via telehealth until January 1, 2026. NASW believes this decision builds on lessons learned during the COVID-19 PHE and highlights the vital role of technology in improving access to care. The association supports CMS's efforts to increase flexibility while maintaining access to behavioral health services. Much emphasis was placed on the need to balance regulatory compliance with service availability to rural communities.
Payment for Preventive Vaccine Costs in RHCs and FQHCs
CMS finalized the following proposals, all of which had been supported by NASW:
allowing RHCs and FQHCs to bill for the administration of Part B–covered preventive vaccines (COVID-19, hepatitis B, influenza, and pneumococcal) at the time of service
instituting additional payment for in-home administration of these vaccines, provided that the home visit meets the requirements both for Part B preventive vaccine administration and for RHC and FQHC services in the home
Payment for Dental Services Furnished in RHCs and FQHCs
CMS finalized its proposal to clarify that when RHCs and FQHCs furnish dental services that align with the policies and operational requirements in the physician setting, those dental services are considered a qualifying visit and are reimbursed according to RHC and FQHC payment methodology. In its comments on the proposed rule, NASW expressed support for this clarification. Moreover, CMS has stated:
It will issue additional instructions and education through subregulatory guidance on the policy and billing requirements for dental services furnished in RHCs and FQHCs.
It will clarify in subregulatory guidance that RHCs and FQHCs can bill separately for dental services that are inextricably linked to other covered services on the same day a medical visit is furnished by an RHC or FQHC practitioner.
Removal of the Term “Grandfathered” in RHC and FQHC Regulations
CMS finalized its proposal to replace the term “grandfathered” with “historically excepted” in §§ 405.2452, 405.2463, 405.2464, and 405.2469. In its comment on the proposed rule, NASW had supported CMS’s attempt to remove this stigmatizing language from regulations.
Medicare Diabetes Prevention Program (MDPP)
The MDPP (https://www.medicare.gov/coverage/medicare-diabetes-prevention-program) is an evidence-based, nonpharmacological, behavioral intervention program to prevent type 2 diabetes. Medicare beneficiaries with certain risk factors may participate in the program, without cost sharing, once during their lifetime. (CMS allows beneficiaries whose services were interrupted by COVID-19 to restart the program.) Although the program was designed to be conducted in person, the COVID-19 pandemic prompted CMS to authorize Medicare payment for MDPP delivery in a virtual or hybrid format, among other flexibilities.
The CY 2025 final rule includes multiple provisions to align MDPP requirements with those of the Diabetes Prevention Recognition Program’s 2024 standards, as established by the Centers for Disease Control and Prevention (https://www.cdc.gov/diabetes-prevention/media/pdfs/legacy/dprp-standards.pdf). Among those finalized proposals are three that were particularly supported by NASW:
clarification that chatbots and artificial intelligence forums do not constitute live interaction for the purpose of online MDPP sessions
allowance of self-reported weights to be obtained either via observation by the MDPP Coach or submission by the beneficiary of date-stamped photos or a video recording (CMS modified its proposal to allow one or two date-stamped photos, as specified on page 98046 of the final rule)
distinctions between in-person and distance learning delivery for MDPP core and maintenance sessions
Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Permanently Allow Periodic Assessments to Be Furnished via Audio-Only Telecommunications
CMS finalized its proposal to allow OTPs to furnish periodic assessments using audio-only communications technology when video is not available on a permanent basis beginning January 1, 2025. Under this regulation, periodic assessments are allowed via audio-only telecommunications when video is not available to the extent that use of audio communications technology is permitted under the applicable Substance Abuse and Mental Health Services Administration (SAMSHA) and Drug Enforcement Administration (DEA) requirements at the time the service is furnished and that all other applicable requirements are met. NASW is pleased that beneficiaries who receive buprenorphine, methadone, and/or naltrexone at OTPs may participate in period assessments via audio-only telecommunications on a permanent basis.
Allow OTPs to Use Audio–Video Telecommunications for Initiation of Treatment with Methadone
CMS had proposed to allow OTPs to use two-way audio–video communications technology for the initiation of treatment with methadone, to the extent that the use of audio–video telecommunications technology to initiate treatment with methadone is authorized by DEA and SAMSHA at the time the service is furnished. NASW supported this proposal. CMS did not propose to extend the flexibility to allow the use of audio-only telecommunications for intake activities for initiation of treatment with methadone because DEA and SAMHSA do not currently permit these flexibilities.
Having considered existing SAMHSA and DEA guidance and reviewed public comments on the proposed rule, CMS has finalized that methadone treatment can be initiated, as clinically appropriate, via audio–video communication if the OTP determines that adequate evaluation of the patient can be accomplished with the use of audio–video communication. The intake HCPCS add-on code G2076 is used to identify such service.
Payment for SDOH Risk Assessments within OUD Treatment Services
CMS proposed to establish payment for SDOH risk assessments as part of intake activities within OUD treatment services under two conditions: (1) These SDOH risk assessments are medically reasonable and necessary for the diagnosis or treatment of an OUD, and (2) OTPs have a reason to believe that unmet HRSN screening or the need for harm reduction intervention or recovery support services identified during an SDOH risk assessment could interfere with the OTP’s ability to diagnose or treat the patient’s OUD. In its comments on the proposed rule NASW supported CMS’s proposal, which acknowledged the complex work OTPs do with beneficiaries. Additionally, NASW had recommended that CMS update the frequency in which the codes could be used, given that circumstances may change during OUD treatment, and to consider direct payment to CSWs for SDOH risk assessment.
The final rule established payment for SDOH risk assessment conducted as part of intake activities and periodic assessments. Such assessment must relate to the diagnosis or treatment of OUD and the efforts to address risk and HRSNs. CMS did not mention direct payment to CSWs for this service. However, the agency pointed out that appropriately licensed or credentialed personnel should be used to address each beneficiary’s needs and goals in regard to education, vocational training, and employment; medical and psychiatric services; psychosocial, economic, legal, housing, and other recovery support services.
Payment for Coordinated Care and Referrals to Community-Based Organizations that Address Unmet HRSNs, Provide Harm Reduction Services, and/or Provide Recovery Support Services
Based on the public comments received, CMS has established new codes for coordinated care and/or referral services, CHI, PIN, PIN–peer support (PIN–PS), and peer recovery support services. CMS has specified there is no limit to which providers can furnish the services related to these new codes; however, the practitioners who provide the services must be authorized under State law, including by licensure, certification, and/or training for these services before furnishing them to Medicare beneficiaries. Additionally, CMS has not limited the amount of time these services can be provided if they are medically reasonable and necessary and related to the treatment of OUD.
Medicare Part B Payment for Preventive Services
CMS finalized several proposals—all supported by NASW—to increase access to vaccines among Medicare beneficiaries:
continued in-home additional payment for the administration of COVID-19, influenza, hepatitis B, and pneumococcal vaccines in a beneficiary’s home; this payment increases access to vaccination for beneficiaries who cannot leave their homes without great difficulty
extending Medicare coverage of hepatitis B vaccination to beneficiaries who have not previously received a completed hepatitis B vaccination series or whose vaccination history is unknown and aligning payment for hepatitis B vaccines and their administration in RHCs and FQHCs with rates for COVID-19, influenza, and pneumococcal vaccines in those settings; these changes will reduce hepatitis B acquisition among Medicare beneficiaries
waiving of beneficiary cost sharing for the administration or supplying of drugs covered as additional preventive services (DCAPS), including in RHCs and FQHCs; this proposal is congruent with Medicare coverage of other preventive services
Medicare Prescription Drug Inflation Program
The Inflation Reduction Act (IRA) of 2022 (Pub. L. 117–169) included provisions to decrease prescription drug costs for Medicare beneficiaries. Among numerous provisions related to the IRA and prescription drug cost inflation, CMS finalized the following proposed policies, all supported by NASW:
The IRA has already decreased the coinsurance for certain Part B drugs if the drug’s price increases more quickly than the inflation rate in a given benchmark quarter. New regulatory provisions finalized at §§ 427.200 and 427.201 codify the policies regarding the computation of that inflation-adjusted beneficiary coinsurance.
The IRA saves money for the Medicare program by requiring prescription drug manufacturers to pay a rebate to CMS if they increase their prices for certain drugs more quickly than the rate of inflation. If a manufacturer fails to pay that rebate, CMS has the authority to assess civil money penalties (CMPs, or fees) to ensure compliance. CMS finalized multiple provisions related to CMP calculation and enforcement. Although NASW did not offer comments on the details of CMP calculation and enforcement, the association supported the use of CMPs for manufacturers’ failure to pay specified rebate amounts for applicable drugs under Part B.
Medicare Parts A and B Overpayment Provisions of the Affordable Care Act
The final rule addresses updates to overpayment provisions under Medicare Parts A and B, as mandated by the Affordable Care Act (Pub. L. 111–148). Clinical providers, including CSWs, are responsible for identifying overpayments within a specific time frame. CMS understands that providers and suppliers need time to investigate, calculate, report, and return certain overpayments. To address this concern, CMS has finalized § 401.305(b)(3), which suspends the 60-day requirement to report and return overpayments for up to 180 days. This extension provides providers and suppliers time to conduct a timely and good-faith investigation to determine whether overpayments related to the same or similar causes as the initially identified overpayment may exist.
NASW appreciates CMS’s efforts to provide clarity and flexibility in reporting and returning overpayments. The changes to § 401.305(b)(2) and the new § 401.305(b)(3) provide more time for thorough investigations before reporting overpayments, thereby preventing premature penalties. This approach supports providers by ensuring overpayments are fully investigated before being reported. In its comments on the proposed rule, NASW had asked CMS to consider creating overpayment restrictions for Medicare Advantage Plans in future rulemaking. CMS responded that this topic was out of scope for CY 2025. NASW will continue to seek opportunities to advocate for social workers on this issue.
Quality Payment Program
CMS finalized three clinical quality measures (CQMs) for CSWs.
New: CQM 503—Gains in Patient Activation Measure (PAM) Scores at 12 Months
CMS finalized the addition of "Gains in Patient Activation Measure (PAM®) Scores at 12 Months" (CQM 503) to the Clinical Social Work Specialty Set for the 2025 performance period. This measure, which is relevant across care settings and particularly pertinent to chronic conditions, evaluates changes in patients' knowledge, skills, and confidence in managing their health. In its comments on the proposed rule, NASW supported CMS’s inclusion of this measure while noting implementation challenges (such as resource requirements) and recommending solutions, such as training and integrating the measure into electronic health record systems to improve feasibility and consistency.
Modified: CQM 181—Elder Maltreatment Screen and Follow-Up Plan
CQM 181 measures the percentage of patients 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter and a documented follow-up plan on the date of the positive screen. CMS finalized its proposal to add this CQM to the Emergency Medicine Specialty Set for the CY 2025 performance period/2027 MIPS payment year and future years. In its comments on the proposed rule, NASW strongly supported CMS’s proposal, noting that that the emergency department is a prime setting for elder maltreatment identification and follow-up planning. Furthermore, in response to CMS’s request for input on the value of any CQM addressed in the final rule, NASW emphasized the relevance of CQM 181 within the measure specialty sets for CSWs and SNFs.
Modified: CQM 504—Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk
CQM 504 is a high-priority CQM that provides suicide assessment and safety planning data. CMS had proposed updating the measurement criteria from patients 18 years and older to patients 12 years and older. NASW supported this proposed change while encouraging CMS to decrease the age further to 10 years and older.
CMS reviewed public comments and finalized its proposed criterion of 12 years and older. Yet, CMS provided guidance to discuss potential updates to this measure in the future. CMS also encouraged public commenters to discuss a lower age range with the measure steward, the American Psychiatric Association. NASW appreciated the opportunity to discuss this measure, which is essential to capturing data for child, adolescent and adult patients who experience suicidal risk, thoughts, and behavior.
*Visit https://www.federalregister.gov/documents/2024/12/09/2024-25382/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other to read the Medicare PFS final rule for CY 2025.