Looking Ahead to 2026 Advocacy Priorities in Light of CMS’ Final Rule

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Looking Ahead to 2026 Advocacy Priorities in Light of CMS’ Final Rule

The 2025 payment rule was a mixed bag for surgery centers

BY KARA NEWBURY | NOVEMBER 22, 2024

With the turnover in administration, the Centers for Medicare & Medicaid Services’ (CMS) 2025 final payment rule for ASCs and hospital outpatient departments (HOPD) creates different opportunities for ASCA to push through its advocacy priorities in 2026.

CMS released its 2025 final rule on November 1.

Conversion Factor Update

CMS will continue to use the hospital market basket (HMB) as the ASC inflation update factor for 2025, which is currently slated as the last year for its use. This results in an effective update of 2.9 percent for ASCs—a combination of a 3.4 percent inflation update based on the HMB and a productivity reduction of 0.5 percentage points mandated by the Affordable Care Act. This is an increase of 0.3 percent from the proposed rule. Please note that this is an average, and updates might vary significantly by code and specialty.

Based on this final update, CMS estimates that total payments to ASCs—including beneficiary cost sharing and estimated changes in enrollment, utilization and case mix—for CY 2025 will be approximately $7.4 billion, an increase of approximately $308 million compared to estimated CY 2024 Medicare payments.

For HOPDs, CMS estimates total payments will be approximately $87.7 billion, an increase of $4.7 billion compared to estimated CY 2024 Medicare payments. Projected ASC payments represent 7.8 percent of the spend between ASCs and HOPDs.

If the secretary of the US Department of Health and Human Services (HHS) does not specify which update to use, the default under current law is the Consumer Price Index for All Urban Consumers (CPI-U), which was used to update ASC rates prior to 2019. The CPI-U has historically been lower than the HMB. ASCA successfully advocated for the HMB to be used in 2019 rulemaking during the first Trump administration and will prioritize the extension of this policy in 2026 advocacy.

Additions to the ASC-CPL

CMS finalized the addition of 21 procedures to the ASC-CPL, including 19 dental codes. The agency also added two adipose-derived regenerative cell (ADRC) therapy codes (short descriptor in parentheses):

  • 0717T (Adrc ther prtl rc tear)
  • 0718T (Adrc ther prtl rc tear njx)

CMS did not finalize the addition of the two leadless pacemaker codes (0795T and 0801T) it had included in the proposed rule. The agency cited a policy in the Medicare Claims Processing Manual, Chapter 32, Section 380.1.1 that limits these procedures to the following sites of service: Indian health service provider based facility, inpatient hospital, on campus-outpatient hospital and military treatment facility.

Regarding the codes ASCA requested, CMS did not respond to each code individually but instead grouped its response.

Cardiovascular codes, including cardiac ablations, cardioversion, electrophysiological studies and procedures, and echocardiography: CMS claimed, “Many of these codes have associated inpatient admissions, where the beneficiary requires active medical monitoring and care at midnight following the procedure. The cardioversion and echocardiography codes are nonsurgical procedures, which means they would not qualify for addition to the ASC CPL, and most of the ancillary codes are not integral to a covered surgical procedure on the ASC CPL.”

Musculoskeletal codes (arthrodesis procedures): CMS indicated that “while these procedures have some claims volume in the outpatient setting, the claims also showed multiple postoperative inpatient days, indicating that the beneficiary would require active monitoring and care past midnight following the procedure. These procedures can also involve prolonged invasion of body cavities. In addition, we acknowledge the findings of studies that commenters provided related to these procedures. However, the studies we received had significant limitations including selection bias and an absence of age groups representative of the Medicare population.”

ASCA disagrees with CMS’ responses and will continue to work with the appropriate specialty organizations and facilities performing these procedures to advocate for the addition of these procedures. In 2021, in the final rule of the first Trump administration, CMS added hundreds of codes to the ASC-CPL before removing them in 2022 rulemaking. For 2026, ASCA will aggressively advocate for the addition of all the procedures its clinicians are able to perform safely in the outpatient setting.

Changes to the ASC Quality Reporting Program

CMS finalized the adoption of the following measures for the ASC Quality Reporting (ASCQR) Program:

  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.

More information on the Facility Commitment to Health Measure is available on the QualityNet site, including the measure specifications as well as attestation guidance. While ASCA will continue to raise concerns about these measures, the Facility Commitment to Health Measure is slated to go into effect for 2025 data collection, so facilities should proceed as if it is required until future rulemaking.

ASCA also will advocate for the removal of ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel as soon as possible, but for now, it remains in the ASCQR Program.

ASCA Resources

ASCA prepares several resources annually to help its members understand Medicare’s final payment rule. Registration is still open for ASCA’s final webinar of the year, “Understanding Medicare’s 2025 Final Payment Rule,” which will take place Tuesday, December 3, at 1:00 pm ET.

In addition, ASCA Chief Executive Officer Bill Prentice and ASCA Chief Advocacy Officer Kara Newbury discuss the final rule on the newest episode of ASCA’s Advancing Surgical Care Podcast. Topics include disappointment with the new process for adding new procedures to the ASC-CPL, concerns related to the inflation adjustment ASCs will receive and difficulties involving several new quality reporting requirements included in ASCQR Program this year.

Web resources, including the Medicare Rate Calculator and Medicare Payment Resources document—both updated quarterly—can be found on ASCA’s Medicare Payment Resources webpage.

Write Kara Newbury with any questions.