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CMS Releases 2025 Proposed Medicare Payment Rule

The agency extends the alignment of ASC and HOPD update factors through 2025

BY KARA NEWBURY | JULY 11, 2024

The Centers for Medicare & Medicaid Services (CMS) released the 2025 proposed payment rule for ASCs and hospital outpatient departments (HOPD) on July 10. Of note, CMS concurred with ASCA’s request and proposed to continue to align the ASC update factor with the one used to update HOPD payments, extending the five-year interim period an additional two calendar years (CY) through 2025.

Other initial observations about the 984-page proposal follow. ASCA will provide additional analysis soon, including a rate calculator that allows users to determine what ASCs will be paid locally if the proposal is adopted.

2.6 Percent Average Rate Update

If the proposed rule were to be finalized as drafted, ASCs would see, on average overall covered procedures, an effective update of 2.6 percent, which is a combination of a 3.0 percent inflation update based on the hospital market basket and a productivity reduction mandated by the Affordable Care Act of 0.4 percentage points. This is an average and the updates might vary significantly by code and specialty. It is important to note that CMS does not consider sequestration in its proposed rules. This statutory 2.0 percent reduction remains in effect unless Congress acts.

The information below provides a comparison between the 2025 ASC and HOPD reimbursement proposals.

CMS estimates that the proposed increase will result in $7.4 billion in total payments to ASCs in 2025, an increase of $202 million compared to estimated CY 2024 payments.

Changes to the ASC Covered Procedures List

CMS proposed to add 20 medical and dental surgical procedures to the ASC Covered Procedures List (ASC-CPL) for CY 2025, as shown in Table 82 starting on page 574 in the rule.

CMS did not propose to add any of the 18 codes ASCA submitted in response to the ASC-CPL Pre-Proposed Rule Recommendation Request back in March. The recommendation request process is a new way to submit codes for consideration that CMS rolled out this year. ASCA submitted 16 cardiovascular codes and two spine codes for consideration. In this proposed rule, CMS did not even mention that the procedures had been submitted for consideration.

“It is disheartening that CMS established a new, supposedly more transparent process for submitting procedure codes that could be added to the ASC Covered Procedures List, yet proceeds in this proposed rule to ignore the 18 cardiac and spine codes we submitted,” said ASCA chief executive officer Bill Prentice. “Medicare beneficiaries would have more access to the care they need if the agency simply relied on the clinical expertise of surgeons who safely perform these procedures and who are best positioned to know where they can be performed.”

Changes to the ASC Quality Reporting Program

CMS proposed to adopt the following measures to the ASC Quality Reporting (ASCQR) Program even though they have not been tested in the ASC setting:

1. the Facility Commitment to Health Equity (FCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination;
2. the Screening for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and
3. the Screen Positive Rate for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination.

The agency also proposed to add these measures to the Hospital Outpatient Quality Reporting Program.

In addition to the cross-program proposals, CMS has requested public comment on the “potential development of frameworks for specialty focused reporting and minimum case number for required reporting under the ASCQR Program.”

Unfortunately, CMS kept ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel in the ASCQR Program. ASCA will continue to oppose this burdensome measure.

The agency did not make any changes to the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey, a patient experience survey, which becomes a mandatory component of the ASCQR Program on January 1, 2025. The June-July Regulatory Review provides more information on this requirement.

ASCA staff will continue to analyze the rule in detail and provide more information to help ASC operators understand the impact of the proposal on their centers soon.

Comments are due September 9, 2024.

Write Kara Newbury with any questions.