CMS is making key changes to the Hospital Outpatient Prospective Payment System (OPPS) that will affect everything from devices to diagnostic radiopharmaceutical cost and application.
Five key takeaways from a Nov. 7 blog post by Coronis Health break down the most important changes healthcare leaders need to know and how they'll impact operations.
- OPPS payment rates are increasing for 2025. The final rule includes a 2.9% increase for hospitals meeting quality reporting requirements. The update is based on a 3.4% market basket percentage increase, offset by a 0.5 percentage point productivity adjustment.
- For both the Intensive Outpatient Program (IOP) and the Partial Hospitalization Program (PHP), the final rule maintains existing rate structures with separate ambulatory payment classifications for three and four or more services per day. For 2025, CMS will use 2023 claims data and cost reports to set payment rates, including data from both PHP and non-PHP days, aiming to capture comprehensive service use.
- Certain non-opioid pain relief treatments in the hospital outpatient department setting will receive additional payments from 2025 to 2027. This measure, aligned with Section 4135 of the 2023 Consolidated Appropriations Act, sets payment limitations based on top OPPS procedures by volume and addresses statutory requirements for qualifying drugs and devices.
- CMS will refine the payment policy for high-cost diagnostic radiopharmaceuticals in 2025 by providing separate payments for those exceeding $630 per day, improving payment accuracy for nuclear medicine tests and aiding patient access to necessary radiopharmaceuticals.
- 2025 is the final year for CMS' policy that provides a $10 add-on payment for Technetium-99m (Tc-99m) produced without highly enriched uranium. However, to address concerns around the domestic supply chain for molybdenum-99 (Mo-99), the source material for Tc-99m, and possible payment inequity, CMS has established a new add-on payment of $10 per dose for radiopharmaceuticals that use Tc-99m derived from domestically produced Mo-99 — starting Jan. 1, 2026.