Additional Details
Payment Updates
- OPPS Payment Update: CMS is proposing to increase payments under OPPS by 2.6%. This is based on a projected hospital market basket increase of 3.0% reduced by a proposed productivity adjustment of 0.4%. CMS estimates that total payments to OPPS providers for CY 2025 will increase by approximately $5.2 billion compared to CY 2024 OPPS payments.
- CMS will also continue to implement the statutory two percentage point reduction in payment for hospitals that fail to meet quality reporting requirements.
- ASC Payment Update: From CY 2019 to CY 2023, CMS adopted a policy to update the ASC payment system using the hospital market basket update. Following the COVID-19 public health emergency, CMS extended this policy by an additional two years—through CY 2024 and CY 2025. As such, CMS is using the hospital market basket methodology to propose an update of 2.6% for ASCs in CY 2025. CMS estimates that total payments to ASCs will increase by approximately $202 million compared to the CY 2024 ASC payment.
Coding and Coverage Changes
- Changes to ASC Covered Procedures and Ancillary Services Lists: For CY 2025, CMS is proposing to add 20 medical and dental procedures to the ASC covered procedures and ancillary services lists.
- Changes to Inpatient Only (IPO) List: For CY 2025, CMS is proposing to add three CPT codes to the IPO list. These are codes are newly created by the AMA CPT Editorial Panel and will be effective January 1, 2025. They include:
- CPT 0894T (cannulation of the liver allograft in preparation for connection to the normothermic perfusion).
CPT 0895T (connection of liver allograft to normothermic machine—initial four hours of monitoring).
CPT 0896T (connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour).
- Continuous Eligibility in Medicaid and CHIP: CMS is proposing to codify the requirement of the Consolidated Appropriations Act (CAA) of 2023, which requires states to provide 12 months of continuous eligibility to children under the age of 19 in Medicaid and CHIP.
- However, CMS is proposing to remove the previous option of applying continuous eligibility to a subgroup of enrollees or limiting continuing eligibility to a time period of less than 12 months. For CHIP, CMS is proposing to remove failure-to-pay premiums as an optional exception to continuous eligibility.
- Access to Non-Opioid Treatments for Pain Relief: CMS is proposing to implement another provision of the CAA, which provides temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient and ASC settings through 2027. CMS is proposing that seven drugs and one device qualify as non-opioid treatments for pain relief starting in CY 2025.
- Payment for Specialized Diagnostic Radiopharmaceuticals: Currently, the costs associated with radiopharmaceuticals are packaged into the payment for nuclear medicine tests with which they are used. CMS is proposing to refine this packaging policy by paying separately for any diagnostic radiopharmaceutical with a per-day cost greater than $630 and removing their costs from the payment amount for the nuclear medicine tests. Diagnostic radiopharmaceuticals with a lower per-day cost would continue to be policy-packaged.
- Exclusion of Cell and Gene Therapies from Comprehensive Ambulatory Payment Classification (C-APC) Packaging: CMS is proposing to exclude nine qualifying cell and gene therapies from C-APC packaging. These therapies are generally used for the treatment of certain rare ocular or spinal conditions, and when administered, are the primary treatment being provided to a patient and thus are not integral, ancillary, supportive, dependent, or adjunctive to any primary C-APC services. For this reason, CMS proposes not to package payment for these therapies into the payment for the primary C-APC service. CMS is seeking comment on whether any other changes to the C-APC packaging policy should be considered.
Quality Programs
- Hospital Outpatient Quality Reporting (OQR) Program: For CY 2025, CMS is proposing several additions to the OQR program as well as the removal of two measures. Hospitals that do not meet quality reporting requirements will receive a reduction of two percentage points in their annual payment update.
- CMS is proposing to adopt the following measures:
- Hospital Commitment to Health Equity (HCHE) measure, beginning in CY 2025
- Screening for Social Drivers of Health (SDOH) measure, with voluntary reporting in CY 2025 followed by mandatory reporting in CY 2026
- Screen Positive Rate for SDOH measure, with voluntary reporting in CY 2025 followed by mandatory reporting in CY 2026
- Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, a patient-reported outcome measure, with voluntary reporting in the CY 2025 followed by mandatory reporting in CY 2026
- CMS is proposing to remove the following measures beginning in CY 2025:
- MRI Lumbar Spine for Low Back Pain measure
- Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery measure
- CMS is proposing to adopt the following measures:
- Ambulatory Surgical Center Quality Reporting (ASCQR) Program:
- CMS is proposing to adopt the following measures.
- Facility Commitment to Health Equity (FCHE) measure, beginning in CY 2025
- Screening for SDOH measure, with voluntary reporting in CY 2025 followed by mandatory reporting in CY 2026
- Screen Positive Rate for SDOH measure, with voluntary reporting in CY 2025 followed by mandatory reporting in CY 2026
- CMS is also seeking comment on a request for information (RFI) regarding development of a Specialty-Focused Reporting and Minimum Case Number for Required Reporting framework. This framework would revise reporting requirements by only requiring ASCs to report on quality measures that are applicable to conditions they treat and/or procedures they perform through use of factors such as case minimums.
- CMS is proposing to adopt the following measures.
Other Updates
- Device Pass-Through Applications: CMS received 14 applications for device pass-through payments on which they are soliciting public comment. CMS will make final determinations on these applications in the CY 2025 OPPS/ASC final rule.
- Review Time Frame for Hospital Outpatient Department (OPD) Prior Authorization Process: CMS is proposing a change to the current review time frame for prior authorization requests from 10 business days to 7 calendar days for standard review.
- Obstetrical Services Conditions of Participation (CoP): CMS is proposing revisions to the current CoP for OB services in an effort to combat the maternal health crisis and improve health and safety. These revisions cover factors including organizational structure and staffing, service delivery standards, staff training, quality assessment, emergency room readiness, and transfer protocols.
LEARN MORE ABOUT ECG'S RELATED SERVICES.
Edited by: Matt Maslin
Published July 16, 2024
You Might Also Like
