On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the CY 2025 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule which issues Medicare payment rates for hospital outpatient and ASC services for calendar year (CY) 2025. Additionally, CMS finalized the CY 2025 Physician Fee Schedule (PFS) which provides for Medicare payments under the PFS and other Medicare Part B policies.
Key takeaways from both the OPPS/ASC and MPFS final rules are consistent with CMS’s proposed rule:
- Increasing OPPS payment rates by 2.9% while decreasing average MPFS payment rates by 2.93%;
- CMS’ efforts to preserve some important, but limited, telehealth flexibilities in their authority, and expand the scope of and access to telehealth services where appropriate.
- Introducing new measures in both rules to prevent and treat Opioid abuse, including increased reimbursement rates for certain services;
- Enhancing access to primary care via a new set of “Advanced Primary Care Management Services” (APCM) codes that focus on care quality rather than time spent with the beneficiary; and
- Updating several quality reporting program metrics for outpatient, ASC, and REHs.
CY 2025 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule
CMS is adopting provisions in the proposed OPPS/ASC rule for the following:
- Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) Rate Setting
- Access to Non-Opioid Treatments for Pain Relief
- Obstetrical Services’ Conditions of Participation
- Hospital Inpatient and Outpatient Quality Reporting (IQR) Programs
- Rural Emergency Hospital Quality Reporting (REHQR) Program
- Ambulatory Surgical Center Quality Reporting (ASCQR) Program
Updates to OPPS and ASC Payment Rates
CMS is finalizing an update to OPPS payment rates of 2.9% for hospitals that meet applicable quality reporting requirements. Similarly, applying the hospital market basket update to ASC payment system rates, CMS is finalizing an update factor for CY 2025 of 2.9%. These updates are based on the projected hospital market basket percentage increase of 3.4% reduced by a 0.5 percentage point productivity adjustment.
Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule
CMS is adopting provisions in the proposed MPFS rule for the following:
- Telehealth Services under the PFS
- Advanced Primary Care Management Services (APCM)
- Behavioral Health Services
- Opioid Treatment Programs (OTPs)
- Certification of Therapy Plans of Treatment with a Physician or NPP Order
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Medicare Prescription Drug Inflation Rebate Program
CY 2025 PFS Rate Setting and Conversion Factor Update
By factors specified in law, average payment rates under the PFS will be reduced by 2.93% in CY 2025, compared to the average amount these services were paid for most of CY 2024. The change to the PFS conversion factor incorporates the 0% overall update required by statute, the expiration of the temporary 2.93% increase in payment for CY 2024 required by statute, and a relatively small estimated 0.02% adjustment necessary to account for changes in work relative value units (RVUs) for some services. This amounts to an estimated CY 2025 PFS conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29.
For more information on the Final Rules, please contact Advis.
