What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2025 outpatient prospective payment system proposed rule.
What else to know: The rule includes a net market basket update of 2.6%. As a result of all proposed changes, CMS estimates that hospital outpatient payments will increase by $1.8 billion in CY 2025, excluding changes in enrollment, case mix, and utilization.
Other key provisions of the proposed rule include:
- Ambulatory Surgical Center Payment Update: A payment update of 2.6% for ambulatory surgical centers that meet quality reporting requirements, resulting in an increase in payments relative to 2024 of $202 million.
- Inpatient Only List (IPO): Adding three procedures to the IPO list.
- Remote Services: Clarifying policies for remotely furnished outpatient therapy services, diabetes self-management training, medical nutrition therapy services, and mental health services furnished remotely in beneficiaries’ homes by hospital staff to maintain alignment across payment systems.
- Diagnostic Radiopharmaceuticals Separate Payment: Create a separate payment for high-cost radiopharmaceuticals with a per
- Exclude Cell and Gene Therapies from Comprehensive Ambulatory Payment Classification (C-APC) Packaging: Exclude qualifying therapies from C-APC packaging policies.
- Policies Related to Incarcerated Individuals: The rule proposes to narrow the definition of “custody” to reduce the population affected by the incarnation payment exclusion. It is also making similar changes to the Medicare special enrollment period for incarcerated individuals.
- Obstetrical Services Conditions of Participation: CMS proposes new Conditions of Participation for hospitals and critical access hospitals for obstetrical services, including new requirements for maternal quality assessment and performance improvement (QAPI), baseline standards for the organization, staffing, and delivery of care within obstetrical units, and staff training on evidence-based maternal health practices on an annual basis.
- Quality Reporting Programs: New measures are proposed for the hospital outpatient quality reporting program — including health equity measures and a patient-reported outcome measure — and several measures are proposed for removal. CMS also proposes modifications to the inpatient quality reporting program Hybrid Hospital-Wide Readmission and Hybrid Hospital-Wide Standardized Mortality measures to extend voluntary reporting. CMS also proposes policies for the Ambulatory Surgical Center and Rural Emergency Hospital quality reporting programs.
- Overall Hospital Quality Star Rating: CMS is considering modifying the Overall Hospital Quality Star Rating methodology to increase focus on the Safety of Care measure group.
CMS’ detailed fact sheet is available here. CHA will make a detailed summary available shortly. Comments are due Sept. 9.
