Outpatient PPS

AT A GLANCE

CMS Outpatient PPS and ASC Final Rule for CY 2025
November 4, 2024

The Centers for Medicare & Medicaid Services (CMS) Nov. 1 released its calendar year (CY) 2025 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) final rule. The rule increases OPPS rates by a net 2.9% in CY 2025 compared to CY 2024. CMS also establishes a new obstetrical services Condition of Participation (CoP) and updates existing quality assessment performance improvement (QAPI), emergency readiness and discharge planning CoPs for hospitals and critical access hospitals (CAHs). The policies and payment rates will generally take effect Jan. 1, 2025.
 

Key Highlights

CMS’ final rule will:

  • Increase OPPS rates by a net 2.9% in CY 2025 compared to CY 2024.
  • Pay separately for diagnostic radiopharmaceuticals with per-day costs above $630.
  • Exclude qualifying cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging in CY 2025.
  • Implement temporary additional payments for certain non-opioid treatments for pain relief dispensed in hospital outpatient departments (HOPDs) and ASCs.
  • Adopt three new measures related to health equity for the Outpatient, ASC and Rural Emergency Hospital (REH) Quality Reporting Programs (QRP).
  • Extend the voluntary reporting period for two Inpatient QRP measures for two years.
  • Establish a new CoP for hospitals and CAHs offering obstetrical services and update the CoPs for QAPI, emergency services, and discharge planning.
  • Cover and pay for HIV Pre-Exposure Prophylaxis (PrEP) drugs and related services in HOPDs as additional preventive services.

AHA TAKE

According to a statement by AHA Senior Vice President of Public Policy Analysis and Development Ashley Thompson, “Medicare's sustained and substantial underpayment of hospitals has stretched for almost two decades, and today's final outpatient rule only worsens this chronic problem. The agency's final increase of less than 3% for outpatient hospital services will make the provision of care, investments in the health care workforce, and addressing new challenges, such as cybersecurity threats, more difficult. These inadequate payments will have a negative impact on patient access to care, especially in rural and underserved communities nationwide.”

“The AHA fully shares CMS’ goals of improving maternal health outcomes and reducing inequities in maternal care,” said Thompson. “While we appreciate that the final rule provides hospitals with additional implementation time and greater flexibility in how they meet certain requirements, we remain concerned about CMS’ excessive use of Conditions of Participation to drive its policy agenda and the potential risk for these requirements to inadvertently reduce access to maternal care. We believe a less punitive and more collaborative approach would be more effective given that the key drivers of maternal health outcomes are highly complex and involve multiple stakeholders. The AHA remains committed to working with the Administration and other stakeholders to advance a full range of solutions to improve maternal outcomes.”

View the Regulatory Advisory.

Site-Neutral Payment

However, these roles are not explicitly funded; instead, they are built into the overall hospital cost structure and supported by revenues received from providing direct patient care. Hospitals are also subject to more comprehensive licensing, accreditation and regulatory requirements than other settings. Yet some policymakers want to make total payment for a service provided in a hospital the same as when a service is provided in a physician office or ambulatory surgery center.