2025 PFS Final Rule: What's Changing in the Quality Payment Program?

It’s November, which means it’s time to review CMS’s just-released 2025 Physician Fee Schedule (PFS) Final Rule. This year’s final rule did not deviate too much from the PFS Proposed Rule that preceded it. But, across the board, it cements a number of changes to the Quality Payment Program (QPP) that you’ll need to plan around for 2025 and beyond.

A Quick QPP Refresher Course

QPP was born out of the 21st Century Cures Act of 2016 and the Medicare Access and CHIP Reauthorization Act (MACRA). These legislative initiatives aimed to transform the way healthcare professionals are reimbursed for their services and improve the quality of care provided to Medicare beneficiaries.

QPP was officially implemented in 2017 with the goal of emphasizing the transition from volume-based to value-based care.  First, there were two distinct reporting tracks or “frameworks” for Eligible Clinicians: The Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

Traditional MIPS, the larger of the two tracks, allowed clinicians to earn positive payment adjustments based on their performance in four categories: quality, improvement activities (IA), promoting interoperability (PI), and cost.

Since then, CMS has added two more reporting frameworks to the mix. The APM Performance Pathway (APP) is now required for all Medicare Shared Savings Program (MSSP) ACOs. And the MIPS Value Pathway (MVP) will eventually replace Traditional MIPS. MVPs focus on sub-group reporting by specialty type – applicable specialty measures designed for specialists.

Understanding the 2025 PFS Final Rule Highlights

As CMS transitions away from traditional MIPS, there is a lot of overlap in how the changes from the 2025 PFS Final Rule affect each framework. Therefore, we’ve broken down everything you need to know about the PFS Final Rule by reporting category:

• Quality
• IA
• PI
• Cost (this category does not apply to the APP framework)
• Additional Updates

Quality Category: All

Data Completeness Threshold to Remain at 75%

CMS has decided to keep the data completeness threshold at 75% through 2028 for all measure types across all reporting frameworks.

Also see: What is Data Completeness in MIPS

Quality Category: MIPS + MVP

New Quality Measures

CMS is adding 7 new quality measures to your list of reporting options in 2025. Two proposed PRO-PMs (Patient-Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer and Patient-Reported Fatigue Following Chemotherapy among Adults with Breast Cancer) didn’t make the final cut.

eCQMs (Previously Finalized in 2024 Final Rule)

1. CMS1056: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Technology (CT) in Adults – Clinician Level

CQMs

2. Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy
3. Appropriate Germline Testing for Ovarian Cancer Patients
4. Adult COVID-19 Vaccination Status
5. Melanoma: Tracking and Evaluation of Recurrence
6. First Year Standardized Waitlist Ratio (RYSWR)
7. Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (PPPW)

Retired and Modified Quality Measures

CMS agreed to substantive changes to 66 existing quality measures. Of the 11 measures it evaluated for retirement, one will remain active for the time being: Oncology: Medical and Radiation – Plan of Care for Pain.

Retired CQMs

1. Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High-Risk Prostate Cancer
2. Melanoma: Continuity of Care – Recall System
3. Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
4. Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications
5. Clinical Outcome Post Endovascular Stroke Treatment
6. Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
7. Age-Appropriate Screening Colonoscopy
8. Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Antiepidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
9. Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

MVP Population Health Measures

Moving forward, MVP participants will no longer be required to select a population health measure as part of their MVP registration. Instead, CMS will calculate all available population health measures for an MVP participant and apply the highest scoring measure to their quality performance category score.

Quality Category: APP

APP Plus Quality Measure Set Finalized

Meanwhile, under the APP framework, CMS continues to forge ahead with its plans to roll out 11 required quality measures under what it calls the “APP Plus” quality measure set by 2028. These measures have been strategically chosen to align with the Adult Universal Foundation measure set and send a message that eCQMs are the “gold standard” of digital quality measurement.

However, CMS has softened its stance just a smidge, outlining a slightly more gradual year-by-year roll-out than it originally proposed. Specifically, it has delayed the addition of two of the measures by one year each and provided some wiggle room on the last two measures to allow more time for specification development should it be needed.

This modified schedule is intended to give ACOs “the necessary time to become familiar with new measure specifications...so that they can successfully report” the full measure set.

Sunsetting of MIPS CQMs is Delayed

Although CMS had proposed sunsetting MIPS CQMs at the end of 2024, it has decided to extend their availability through 2026. That gives ACOs reporting under the APP framework three measure collection types to choose from between now and 2027: MIPS CQMs, Medicare CQMs and eCQMs.

Also See: eCQMs vs Medicare CQMs – Which is Better for ACOs?

eCQM Incentive is Extended

To encourage more ACOs to make the switch to eCQMs, CMS has confirmed that it will continue offering its eCQM Reporting Incentive in 2025 and beyond. Under this incentive, ACOs can qualify for maximum shared savings by achieving just two scoring benchmarks:

• At or above the 10th percentile of the benchmark on at least one of the four outcome measures in the APP Plus quality measure set; and
• At or above the 40th percentile of the benchmark on at least one of the remaining measures in the APP Plus quality measure set.

There’s just one catch: the incentive only applies if you report all eCQMs in the APP Plus quality measure set. The incentive does not apply to ACOs that report a combination of eCQMs/Medicare CQMs or report only Medicare CQMs.

Also See: How to Take the Leap into eCQMs for ACOs

NEW Complex Organization Adjustment for ACOs

Starting in 2025, ACOs that choose to report eCQMs are eligible to receive a Complex Organization Adjustment to account for all the organizational complexities they face when reporting eCQMs.

Eligible ACOs can earn one bonus measure achievement point for each eCQM they submit in a performance year. The eCQM submission must meet data completeness requirements and case minimum requirements to qualify. ACOs that choose to report CQMs or Medicare CQMs will not qualify for these bonus points.

Medicare CQMs Get a 2-Year Flat Benchmark

If you choose to submit your quality measures as Medicare CQMs, CMS will score them using a flat benchmarking system in your 2025 and 2026 performance years.

Improvement Activities Category: All

NEW IA Measures

CMS will make available 2 new IA measures in 2025:

• Implementation of Protocols and Provision of Resources to Increase Lung Cancer Screening Uptake
• Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk

Retired & Modified IA Measures

CMS is modifying just one measure in 2025 (Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B) and retiring 4 more:

• EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
• ERP_4: Implementation of a Personal Protective Equipment (PPE) Plan
• ERP_5: Implementation of a Laboratory Preparedness Plan
• PSPA_27: Invasive Procedure or Surgery Anticoagulation Medication Management

In 2026, 4 more IA measures will be removed from the QPP program—but they’re still available to you for one more year:

• PM_12: Population Empanelment
• CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
• CC_2: Implementation of Improvements that Contribute to More Timely Communication of Test Results
• BMH_*: Electronic Health Record Enhancements for BH Data Capture

Improvement Activities Category: MIPS + MVP

Streamlining Your IA Requirements

CMS has simplified the IA category in two big ways:

• Reduced the number of activities that clinicians are required to attest to completing
• Removed activity weights to simplify scoring

Promoting Interoperability Category: All

Who Qualifies for Automatic Reweighting Has Changed

Automatic reweighting for clinical social workers in the PI category will end in 2024, as outlined by the 2024 Final Rule. Thus, per the 2025 Final Rule, only the following entities will qualify for automatic reweighting:

• Ambulatory Surgical Center (ASC)-based
• Hospital-based
• Non-patient facing
• Small practice

Cost Category: MIPS + MVP Only!

New Cost Measures

CMS will move forward with adding 6 new episode-based cost measures in 2025. Each measure has a 20-episode case minimum.

• Respiratory Infection Hospitalization
• Chronic Kidney Disease
• End-Stage Renal Disease
• Kidney Transplant Management
• Prostate Cancer
• Rheumatoid Arthritis

Modified Cost Measures

CMS “finalized substantive updates” to 2 existing episode-based cost measures:

• Routine Cataract with Intraocular Lens [IOL] Implantation
• ST-Elevation Myocardial Infarction [STEMI] Percutaneous Coronary Intervention [PCI]

Additional Updates: All

New Qualifying Data Submission Minimums

CMS has established minimum criteria for qualifying your data submissions in the Quality, IA, and PI categories. This is to reduce the number of clinicians who are being unfairly penalized for unintentional submission errors:

• Quality – Submission must include Numerator and Denominator information for at least one Quality measure to be considered a submission.
• Improvement Activities – Submission must include a “yes” response for at least one IA to be considered a submission.
• Promoting Interoperability – All required elements to report objective and associated measures and attestation statements.

Additional Updates: MIPS + MVP 

Score Threshold to Remain at 75 Points

CMS has decided to keep the score threshold at 75 points for 2025.

New and Modified MVPs

Under the MVP framework, CMS finalized the addition of 6 new pathways for 2025:

• Complete Ophthalmologic Care
• Dermatological Care
• Gastroenterology Care
• Optimal Care for Patients with Urologic Conditions
• Pulmonology Care
• Surgical Care

They also made minor modifications to the previously finalized MVPs, most notably consolidating two neurology-focused MVPs (Optimal Care for Patients with Episodic Neurological Conditions and Supportive Care for Neurodegenerative Conditions) into a single MVP: Quality Care for Patients with Neurological Conditions.

These changes bring the total number of available MVPs to 21 for 2025. CMS estimates that, with these changes, 80% of MIPS eligible clinicians will now have applicable MVPs to report under.

See Also: A Guide to Choosing Which MVP to Report

MVP Subgroup Reporting Exception

If you opt to submit MVPs, subgroup reporting is still on track to be mandatory in 2026. However, CMS has agreed to a “small practice multi-specialty” exception to this rule for the time being.

Sunset Date for Traditional MIPS Still Unclear

While CMS anticipated being “ready to full transition to MVPs by CY 2029” in this summer’s proposed rule, the final rule is vaguer, promising simply to “sunset traditional MIPS in the future.” CMS goes on to say that “the future date has not been determined and will be established through the official notice and comment rulemaking process.”

See Also: MVPs - Should I Start Now?

Additional Updates: APP

Prepaid Shared Savings Program Approved

CMS is moving forward with its “prepaid shared savings” program designed for ACOs that have a history of earning shared savings. Under the program, eligible ACOs can receive quarterly advances on their earned shared savings, of which at least 50% must be invested in direct beneficiary services and up to 50% can be invested in staffing and infrastructure needs.

The program, which is expected to officially launch January 1, 2026, will require ACOs to submit an annual application to qualify.

Get Help with Your 2025 QPP Requirements Now

The changes introduced under the 2025 PFS Final Rule reflect the evolving landscape of healthcare quality reporting. Healthcare providers and organizations must adapt to these changes to ensure compliance and maximize their performance within the Quality Payment Program.

Medisolv can help you along the way. Schedule a 1:1 call with us today to see a demo of our Medisolv Platform, which can help you take control of all your reporting requirements across all three frameworks—traditional MIPS, MVP, and APP—with laser focus.

Here are a few links to the CMS documents with this PFS Final Ruling.

• Final Rule
• MSSP ACO Fact Sheet
• QPP Fact Sheet
• 2025 Finalized MVPs Guide