The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service outpatient prospective payment system (OPPS) effective Jan. 1, 2025.
The final rule:
- Provides a net 2% increase to the OPPS conversion factor from $87.38 to $89.17 for hospitals that report quality measure data.
- Increases the outlier fixed-dollar threshold by 3.2% from the current $7,750 to $8,000, as proposed.
- Requires an in-person visit by the beneficiary within six months prior to the provision of remote mental health services and then annually, beginning Jan. 1, 2025. Congress would need to extend previous statutory waivers to continue to waive the in-person visit requirements beyond Jan. 1, 2025.
- Reduces the review timeframe for standard prior authorization requests for covered hospital outpatient department services from 10 business days to seven calendar days.
- Uses 2023 claims data and the most updated cost report data from the Healthcare Cost Report Information System, primarily from 2022, to set payment rates.
- Adds three services (CPT codes 0894T, 0895T and 0896T) for liver allograft-related procedures to the Inpatient-Only List and removes a pelvic fixation code (CPT code 22848) for 2025.
- Updates the core based statistical areas used to determine a hospital’s wage index, consistent with other 2025 final rules. The CMS will use the FY 2025 wage index values from the IPPS correction notice.
- Adds two new status indicators (H1 and K1) to identify Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes representing separately payable, non-opioid post-surgical pain management products, as authorized by the Consolidated Appropriations Act of 2023. The CMS finalized six drugs and five devices that qualify for these payments.
- Establishes separate payment for diagnostic radiopharmaceuticals with a per-day cost exceeding $630, as proposed, with updates in 2026 and subsequent years based on the Producer Price Index for Pharmaceutical Preparations. All qualifying products will be paid separately at their mean unit cost.
- Excludes qualifying cell and gene therapies from comprehensive ambulatory payment classification packaging.
- Adopts three measures related to health equity for the Outpatient, Ambulatory Surgical Center (ASC) and Rural Emergency Hospital Quality Reporting Programs and extending voluntary data reporting for two hybrid measures in the Inpatient Quality Reporting Program.
- Establishes a new condition of participation for hospitals and critical access hospitals that provide obstetrical services including new requirements for maternal quality assessment and performance improvement, and baseline standards for the organization, staffing and delivery of care within obstetrical units, and staff training on evidence-based best practices every two years.
- Extends the virtual direct supervision of therapeutic and diagnostic services under the physician fee schedule (PFS) through Dec. 31, 2025. The CMS also finalized the proposal to extend virtual direct supervision under the OPPS through Dec. 31, 2025, to maintain alignment between the PFS and OPPS.
- Adds 21 medical and dental procedures to the ASC covered procedures list.
The MHA will provide an updated hospital-specific impact analysis within the next few weeks and encourages hospitals to contact Vickie Kunz with questions regarding the final rule.