Yesterday, CMS posted the 2025 Proposed Physician Fee Schedule Rule with a host of proposed changes affecting healthcare providers and suppliers. Specifically for EMS, CMS proposed:

• Adding O+ Blood Transfusion to ALS2 Procedures. CMS proposes to modify the definition of ALS2 at 42 CFR § 414.605 by adding the administration of low titer O+ whole blood transfusion to the current list of seven ALS2 procedures as a new number eight. CMS would also reflect this change in the Medicare Benefit Policy Manual, Chapter 10, Ambulance Services, section 30.1.1, Definition of Ground Ambulance Services. Under this proposal, a ground ambulance transport that provides low titer O+ whole blood constitutes an ALS2-level transport

While CMS did not include alternative blood product treatments in the current Proposed Rule, it is also seeking comment on whether it should add the administration of PRBCs or plasma to the list of ALS2 procedures.

 
How the updated regulation would read if finalized:
 
42 CFR § 414.605, ALS2 means either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures:
 
(1) Manual defibrillation/cardioversion;
(2) Endotracheal intubation;
(3) Central venous line;
(4) Cardiac pacing;
(5) Chest decompression;
(6) Surgical airway;
(7) Intraosseous line.
(8) Administration of low titer O+ whole blood transfusion.

If finalized, this change would likely go into effect on January 1, 2025. 
 
CMS's Rationale
 
As of March 2024, 147 (1.2 percent of the EMS systems in the United States) now carry whole blood products, with 200 or more systems anticipated to provide some form of blood product. 
 
CMS believes that many ground ambulance transports providing whole blood transfusion (WBT) during transport already qualify for ALS2 payment since patients requiring such transfusions are generally critically injured or ill and often suffering from cardio-respiratory failure and/or shock, and therefore are likely to receive one or more procedures currently listed as ALS procedures in the definition of ALS2. However, not all ground ambulance transports providing WBT may already qualify for ALS2 payment. An ambulance transport would not qualify for ALS2 payment where a patient received only WBT during a ground ambulance transport and not one or more other services that, either by themselves or in combination, presently qualify as ALS2. CMS believes WBT should independently qualify as an ALS2 procedure because administering WBT and handling low titer O+ whole blood requires a complex level of care beyond ALS1, for which EMS providers and suppliers at the EMT-Intermediate or paramedic level require additional training. Therefore, CMS says in the Proposed Rule that it is appropriate to modify the definition of ALS2 to account for the instances where patients are administered WBT but do not otherwise qualify for ALS2 payment.
 
CMS says it has no authority to provide an additional payment, such as an add-on payment for the administration of WBT under the AFS.

The 2025 Proposed Physician Fee Schedule Rule is currently in its pre-published form but will be published on 07/31/2024. 

We will discuss this rule and much more at our upcoming conferences. Click HERE to register for an upcoming conference event.