CMS Temporarily Increases Reimbursement for Coronary CT Angiography in 2025

The Centers for Medicare and Medicaid Services (CMS) has temporarily reassigned coronary CT angiography (CCTA) codes 75572-75574 from ambulatory payment classification (APC) 5571 to APC 5572 under the 2025 Outpatient Prospective Payment System (OPPS) final rule.

This change increases national reimbursement rates for CCTA from $175.06 in 2024 to $357.13 in 2025.

The reassignment is temporary and dependent on future billing data, emphasizing the need for hospital revenue cycle and billing departments to be educated and adjust their practices accordingly.

Hospitals should update clinical charge masters to ensure CCTA services are linked to cardiology revenue codes like 0489x (Cardiology – Other) or 0409x (Other Imaging Services), which reflect higher cost-to-charge ratios.

Outdated "Return to Provider" edits (#19) that previously prevented facilities from using cardiology revenue codes have been removed.

Hospitals may need to update internal software or clearinghouse edits to allow the use of cardiology-specific revenue codes for CCTA billing.

These updates will not impact how revenue is tracked across hospital service lines but will ensure more accurate reporting of the greater resources required for cardiac CT imaging compared to general CT services.

This change is the result of advocacy by the American College of Cardiology (ACC), the Society for Cardiovascular Computed Tomography (SCCT), and other stakeholders, who argued that prior coding rules suppressed cost inputs for CCTA.

Until December 2023, hospitals could only bill CCTA using general CT scan (035x) or diagnostic radiology (032x) revenue codes, which underreported the costs of these resource-intensive services.

CMS conducted a simulated cost analysis, finding that if 50% of CCTA codes were billed with cardiology revenue codes, the services would qualify for the higher APC (5572).

CMS acknowledged that while the coding edit was removed, it could take years for hospitals to adopt the new billing practices, prompting the agency to adjust payments temporarily using an alternative methodology.

The agency expects it will take three to four years for the data to fully reflect new billing practices. If no significant changes are observed after this period, CMS will revert CCTA payments to the standard OPPS payment methodology.

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Take-Home Points:

• CMS temporarily increased reimbursement rates for CCTA to $357.13 in 2025 by reassigning it to a higher APC (5572).
• Hospitals must update billing practices to use cardiology revenue codes (0489x or 0409x) to reflect the true costs of CCTA.
• Outdated coding edits that restricted the use of cardiology revenue codes have been removed, facilitating these updates.
• Accurate billing and education are critical to ensure CMS receives sufficient data to make the reassignment permanent.
• The reassignment follows years of advocacy by stakeholders, who highlighted the resource intensity of CCTA compared to general CT services.
• CMS will monitor data over the next three to four years and may revert payments if hospitals fail to adjust billing practices.

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What is Modifier 25?

• Definition: Used to report a significant, separately identifiable Evaluation and Management (E/M) service performed on the same day as another procedure by the same physician or qualified healthcare professional.

Appropriate Use:

• Applies when an E/M service is distinct from the procedure or usual pre/postoperative care.
• Can be appended to E/M codes (99202–99215) when paired with a procedure (e.g., 93015 Cardiovascular stress test).
• Does not require different diagnosis codes for E/M and the procedure.
• Documentation must clearly support the medical necessity for both services.

Examples:

• Appropriate Use: Patient has an E/M visit for chest pain and undergoes a cardiovascular stress test the same day. Use Modifier 25 with the E/M code.
  • Example coding: 99214, 25 and 93015.
• Inappropriate Use: Patient comes in solely for a scheduled stress test. Only the test should be coded (e.g., 93015).

Rules to Remember:

• Documentation: Must substantiate the E/M service as separate and significant from the procedure.
• Link Modifier 25 to the E/M CPT code.
• Modifier 25 is valid for minor surgical procedures (000 or 010-day global period) or non-global indicator (XXX) procedures.
• Do not use Modifier 25:
  • For services during a postoperative period if related to prior surgery.
  • When only an E/M service is performed without a procedure.
  • For major surgeries (90-day global period) unless unrelated to the surgery.

Additional Notes:

• Proper use informs payers to reimburse for both E/M and the procedure.
• Audits often result in payment rescission for inadequate documentation or incorrect coding.
• Modifier 25 can be used for outpatient, inpatient, ambulatory surgery centers, and emergency department visits.

New CMS G Codes for ASCVD Risk Assessment and Management (2025)

 The Centers for Medicare and Medicaid Services (CMS) introduced two new G codes in the 2025 Medicare Physician Fee Schedule to reimburse for ASCVD risk assessment and management services.

The codes are inspired by the CMS Innovation Center’s Million Hearts® Cardiovascular Disease Risk Reduction model, which reduced all-cause death rates by 4% and cardiovascular event death rates by 11% for medium and high-risk patients.

The ASCVD risk assessment code, G0537, involves a standardized, evidence-based risk assessment for patients with ASCVD risk factors, lasting 5-15 minutes, and is billable once every 12 months.

This service applies to patients without a cardiovascular disease diagnosis or history of heart attack or stroke but with at least one predisposing condition like obesity, high blood pressure, or diabetes.

The risk assessment requires current laboratory data, a validated ASCVD risk assessment tool, demographic factors, modifiable risk factors, and possible risk enhancers to produce a documented 10-year ASCVD risk estimate.

Tools like the ACC ASCVD Risk Estimator meet these requirements, and the G0537 code is assigned a work RVU of 0.18.

The ASCVD risk management code, G0538, is for managing intermediate, medium, or high-risk patients identified through an ASCVD risk assessment.

The management service involves creating and implementing an ASCVD-specific care plan that incorporates shared decision-making and addresses risk factors like blood pressure, cholesterol, smoking, and nutrition.

These services include medication management, care coordination, non-face-to-face communication options, and individualized electronic care plans targeting modifiable risk factors.

The G0538 code, assigned a work RVU of 0.18, may apply monthly, but cost-sharing may be required since the service is not classified as preventive.

CMS emphasizes that patient consent is necessary for these services, which can be performed by physicians or qualified health professionals.

Further guidance and resources from CMS for using these codes will be shared by the ACC in the coming weeks.

Take-Home Points: 

• Two new codes (G0537 and G0538) reimburse ASCVD risk assessment and management.
• G0537: Annual risk assessment (5-15 minutes) for patients with predisposing conditions (e.g., obesity, hypertension). Requires a lipid panel and a validated tool like the ACC ASCVD Risk Estimator.
• G0538: Monthly risk management for patients identified as intermediate/high risk. Includes care plans addressing ABCS (Aspirin, Blood pressure, Cholesterol, Smoking cessation) and shared decision-making.
• Patient consent is required; cost-sharing applies to management services.
• Inspired by the Million Hearts® model, which reduced cardiovascular mortality by 11%.