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On November 1
st, CMS released its calendar year 2025 Outpatient Prospective Payment System (OPPS)
Final Rule and Medicare Physician Fee Schedule (PFS)
Final Rule. AHPA will be hosting a webinar next Wednesday at 4 p.m. EST. to go over the finalized policies. To register, please email us by clicking
here. As with any change of Administration, the new Trump Administration may decide to make changes to some of these finalized policies but at this point is uncertain what exactly may change.
OPPS Highlights
- Obstetrical Services Conditions of Participation: CMS finalized its proposal to create a new Conditions of Participation (CoP) for facilities providing Obstetrical (OB) services. In response to feedback, including from AHPA, CMS adopted a phased implementation approach instead of the proposed January 1, 2025 implementation date. Below is the finalized implementation timeline:
- July 2025: Emergency Services Readiness for Hospitals and Critical Access Hospitals (CAH) and Transfer Protocols for Hospitals.
- January 2026: Organization, Staffing, and Delivery of Services for Hospitals and CAHs.
- January 2027: Training for OB staff in Hospitals and CAHs, and Quality Assurance and Performance Improvement (QAPI) Program for OB Services in Hospitals and CAHs. CMS also clarified that participating in quality initiatives and utilize resources such as Perinatal Quality Collaboratives and the AIM patient safety bundles would satisfy the requirement for annual Performance Improvement Programs (PIP) and that the PIPs may extend for multiple years.
- Social Determinants of Health: CMS is finalizing its proposals to adopt:
- The Hospital Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 payment determination.
- The Screening for Social Drivers of Health 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 Screen Positive Rate for Social Drivers of Health 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.
- Prior Authorization: CMS finalized the proposal to shorten the timeframe with which CMS must process prior authorization requests from 10 business days to seven calendar days.
- Nuclear Medicine: CMS has unbundled payment for radiopharmaceuticals, a huge win for patients battling cancer and other diseases requiring nuclear medicine.
- Children’s Health Insurance Program: CMS finalized its proposal to require 12 months of continuous eligibility for children under 19 years of age enrolled in Medicaid or CHIP.
- Barostim Procedure Removal from New Technology Payment Classification: CMS had proposed to remove a procedure (HCPCS Code 0266T - Implantation or Replacement of Carotid Sinus Baroreflex Activation Device) from its current payment classification as a New Technology procedure to the Level 5 Clinical APC, which would have resulted in a significant reimbursement shortfall. In an advocacy win for AHPA, CMS heeded our recommendation to maintain this procedure in its current New Technology APC.
PFS Highlights
- Telemedicine Flexibility Extensions: Originating site location flexibilities that began during the COVID-19 public health emergency and were extended through 2024 by Congress will end, as required by current law. Starting Jan. 1, 2025, telehealth originating site rules will limit patient location to certain rural and underserved areas. Several bills under consideration in Congress would extend or make telehealth flexibilities permanent.
- Starting Jan. 1, 2025, two-way, real-time audio-only communication will satisfy the requirement for an interactive telecommunications system under specific circumstances when a patient cannot use or does not consent to using video technology. However, the distant site practitioner must still have audio-video capabilities.
- ASCVD Risk Assessment and Management G Codes: CMS finalized a proposal to create coding and payment for Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment and risk management services. Risk management services would include the following: aspirin (or other medications), blood pressure management, cholesterol management, smoking cessation.
- Telehealth Home Address Enrollment: Through calendar year 2025, CMS will continue to permit a distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. They will consider this issue further for future rulemaking.
- Quality Payment Program: CMS added six new MIPS Value Pathways (MVPs) to be available for the 2025 performance year, along with revisions to all previously finalized MVPs.
If there are any questions regarding the final rules, you can email AHPA, and we will be happy to get back to you. Contact:
