Key 2025 CMS Coding & Payment Updates
📅 Hospital / Outpatient (OPPS) & Procedure-Code Changes
As of October 1, 2025, CMS rolled out an update to the Hospital Outpatient Prospective Payment System (OPPS) — adding new device pass-through categories for ambulatory surgical centers (ASCs), new HCPCS codes (e.g. for pleural-peritoneal shunt insertion with intercostal pump chamber), and updated codes for drugs, biologics, radiopharmaceuticals, and skin substitutes.
Centers for Medicare & Medicaid Services
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Centers for Medicare & Medicaid Services
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A batch of new skin substitute HCPCS codes (Q4368–Q4380, Q4382) were introduced, assigned status indicator “N” (i.e. packaged into the payment for the associated procedure) due to insufficient pricing data to treat them as separately payable.
nahri.org
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Several HCPCS drug/biologic/radiopharmaceutical codes saw status indicator changes — e.g. codes J9038, Q5151, Q5152 had their status changed to “K” effective April 1, 2025.
nahri.org
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There were also deletions — some codes (e.g. C9173) were removed after being active earlier in 2025.
Bristol Healthcare Services Inc.
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🧪 Laboratory, PLA, and Diagnostic Codes
On April 1, 2025, CMS implemented 21 new CPT “PLA” (Proprietary Laboratory Analysis) codes — CPT 0531U through 0551U — now recognized under OPPS coding.
Centers for Medicare & Medicaid Services
Status indicator changes: e.g. PLA code 0464U was changed retroactively to status indicator “A” (effective October 3, 2024).
Centers for Medicare & Medicaid Services
With the July 2025 Clinical Laboratory Fee Schedule update, there were additional revisions to lab and diagnostic billing, including new / deleted CPT codes and updates to when tests are payable.
Centers for Medicare & Medicaid Services
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🧑⚕️ Billing & Service-Level Changes (Care Coordination, Chronic Care, Telehealth, etc.)
For 2025, the previously used code G0511 (for consolidated care coordination billing by Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs)) was eliminated. From January 1 2025 onwards, RHCs/FQHCs must bill each care coordination service using specific CPT / HCPCS codes — for example, using codes such as 99490 for non-complex Chronic Care Management, or the new codes introduced under the new model.
Newswire
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To support value-based and advanced primary care models, CMS introduced new HCPCS “Advanced Primary Care Management (APCM)” codes: G0556, G0557, and G0558 — stratified by number/severity of chronic conditions.
Newswire
There are also clarifications and updates around payment policies for telehealth and remote services. Some of the older telephone-based E/M codes (e.g. certain CPT telephone E/M codes) have been deprecated in favor of revised billing practices — making it important for practices to stay current to avoid claim denials.
The Hospitalist Community
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🔄 Coding Integrity & Procedure-to-Procedure Edits (NCCI)
As of October 1, 2025, a new version (v 31.3) of the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits goes into effect — meaning certain combinations of CPT/HCPCS codes may now be flagged as incompatible or disallowed, to prevent improper coding and payment.
Centers for Medicare & Medicaid Services
Facilities and providers must ensure their billing systems and coders are updated to the new NCCI logic to avoid denials or compliance issues.
Centers for Medicare & Medicaid Services
📝 Documentation & Assessment Tool Updates — Long-Term Care / MDS / RAI Manual
Per a release mid-2025, CMS published a revised version of the MDS 3.0 RAI User’s Manual — v1.20.1, effective October 1, 2025.
polaris-group.com
Key changes include: renaming/removing certain fields (e.g., “Gender” A0800 replaced by “Sex” A0810), updates to coding for transportation (A1250 → A1255), updates and clarifications in sections such as Mood, Functional Abilities (Section GG), Health Conditions (falls, fractures), Swallowing/Nutrition (weight loss/gain coding), Skin Conditions (pressure ulcers present on admission), and medication risk coding.
polaris-group.com
For long-term care facilities and those using Minimum Data Set (MDS) assessments, this requires immediate attention — updated training for staff, EHR templates, and coding workflows.
polaris-group.com
📅 What These Changes Mean for 2025 and Beyond
Impact Area What to Do / Watch For
Billing & Reimbursement Update all billing systems/EHR software to include new/changed codes (PLA, HCPCS, skin substitutes, lab codes, APCM, etc.) — or risk denials.
Revenue Cycle / Compliance Re-train coding staff on new NCCI edits (PTP v31.3) to avoid incompatible code pairings.
Chronic Care & Care Coordination Switch from legacy codes like G0511; ensure proper use of new CPT/HCPCS codes for chronic care management / care coordination / APCM.
Outpatient / Ambulatory Coding Review skin substitute, biologics, drug-administering codes to ensure correct status indicators and payment designations.
Long-Term Care / MDS-based Facilities Implement updates from MDS 3.0 RAI Manual v1.20.1 — update forms, staff training, documentation protocols.
Telehealth / Remote Services Billing Ensure telehealth billing practices follow updated E/M and telehealth-specific guidance; verify payer acceptance of codes.
✅ What Coders, Billing Staff & Providers Should Do Now
Ensure your EHR / billing software is updated to the latest 2025 code sets and OPPS / NCCI logic.
Inform and retrain clinical & revenue-cycle staff about:
New PLA / lab codes
Skin substitute & biologic/drug-administering codes
APCM and chronic care management billing changes
New NCCI edits — flag incompatible code combinations
MDS 3.0 RAI updates (if applicable)
Audit recent claims (2024/2025) to check for potential denial risk under new rules/codes, especially for outpatient services, drug/biologic claims, and long-term care assessments.
Update documentation templates (note-forms, MDS/RAI forms, chronic care plans) to reflect new coding and data-collection requirements.
Monitor payer communication & guidance — while CMS sets baseline rules, private insurers may adopt different policies or lag in updates (especially for telehealth).
If you like — I can pull up a full list of all major 2025 CMS code changes (HCPCS, PLA, lab, skin-substitute, MDS 3.0) in a spreadsheet-style format — that you (or your team) could download and use to compare against your existing billing codes.
Do you want me to build that list for you now?
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