On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2025 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule [CMS-1809-F], which includes finalized policies to update payment rates and regulations affecting Medicare services furnished in hospital outpatient and ambulatory surgical center (ASC) settings beginning in CY 2025.
For CY 2025, CMS increased payment rates under the Hospital Outpatient Prospective Payment System (OPPS) and the ASC Payment System by 2.9%. In continuation of an existing policy, hospitals and ASCs that fail to meet their respective quality reporting program requirements will be subject to a 2% reduction in the CY 2025 fee schedule increase factor.
CMS estimates, based on the policies, that total payments to OPPS providers and ASCs (including beneficiary cost-sharing and estimated changes in enrollment, utilization, and case mix) for CY 2025 will be approximately $87.7 billion and $7.4 billion, respectively. This growth represents an increase of approximately $4.7 billion and $308 million, respectively, from CY 2024 payment levels.
Key takeaways from the CY 2025 OPPS and ASC Payment System Final Rule:
- CMS did not expand the categories of services subject to prior authorization but finalized a policy to harmonize the timeline for review for non-urgent services and procedures.
- CMS finalized its proposal to make separate payment for non-opioid treatments (including drugs and devices) for pain relief.
- CMS finalized the revision to its current bundling policy for diagnostic radiopharmaceuticals to separately pay for high-cost radiopharmaceuticals with a per-day cost over a specific threshold.
- CMS finalized updates to the ASC covered procedures list (CPL) by adding 21 medical and dental surgical procedures to the list. CMS finalized a decision to remove one code – not originally noted in the proposed rule – from the inpatient only (IPO) list for CY 2025.
- CMS will continue to apply a productivity-adjusted hospital market basket update to ASC payments for CY 2025.
- CMS finalized the policy to expand coverage of colorectal cancer (CRC) screening tests.
- CMS finalized its policy to create exceptions to the Medicaid clinic services benefit four walls requirement.
- CMS finalized new conditions of participation (CoPs) for obstetric services and emergency readiness but will phase in the new requirements over two years.
- CMS finalized its proposals for new quality measures focused on health equity and social drivers of health (SDOH) and reviewed information on how to further address patient safety.
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McDermott+ has developed a dashboard that shows total Medicare fee-for-service payment rates, volumes and geometric mean costs for outpatient stays by HCPCS and APC, as calculated by CMS for the 2025 OPPS final rule. This information can be used to identify the codes driving changes in cost at the APC level over time.
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RESOURCES
- The finalized regulations are available here.
- The press release is available here.
- The fact sheet is available here.
