2025 OPPS proposed rule: Separate payment for radiopharmaceuticals, new obstetrical CoPs in the balance

CMS is considering a significant change to how it pays for certain high-cost radiopharmaceuticals, as well as a sweeping new set of Conditions of Participation (CoPs) aimed at maternal health, and a slew of other changes in the 2025 Outpatient Prospective Payment System (OPPS) proposed rule.

Released July 10, the proposed rule details payment updates, changes to hospital outpatient remote services, new coverage rules, and changes to quality programs and programs designed to reduce health disparities. The proposed rule is scheduled to be published in the July 22 Federal Register, and comments are due September 9.

Payment update

CMS is proposing a 2.6% payment increase. In comparison, the agency proposed a 2.8% increase in the 2023 OPPS proposed rule and finalized a 3.1% increase in the final rule. In a statement, Ashley Thompson, senior vice president of public policy analysis and development for the American Hospital Association (AHA), said the increase is not sufficient to meet hospitals’ needs.

“This proposed increase for outpatient hospital services of only 2.6% comes despite the fact that many hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging,” Thompson said.

Separate payment for radiopharmaceuticals

CMS is proposing to pay separately for diagnostic radiopharmaceuticals with a per day cost of more than $630. Currently, payment for all diagnostic radiopharmaceuticals, regardless of cost, are packaged into the payment for the test. If approved, CMS would remove the cost of these specific radiopharmaceuticals from the payment for the test. The agency believes this will make nuclear medicine tests with higher-cost radiopharmaceuticals more accessible to patients.

Cardiac CT RFI

CMS included a request for information (RFI) on cardiac CT services in the Ambulatory Payment Classification (APC)-specific policies section. The agency states that it has received comments noting that payment for these services has declined since 2017 and that the payment does not cover the cost of providing the services, as well as other concerns about coding for these services and edits applied to claims that affected revenue code reporting.

This is an issue that revenue integrity professionals should pay particular attention to, says NAHRI Advisory Board member John Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president, enterprise revenue management/CDM operations at Atrium/Advocate Health in Charlotte, North Carolina.

“It likely went unnoticed to most that CMS mentioned in the January 2024 OPPS transmittal that an erroneous or outdated return to provider (RTP) edit, which limited providers’ ability to report anything other than a ‘CT Scan’ UB04 revenue code, had been removed, and that providers may report Current Procedural Terminology (CPT^©) codes 75572-75574 with any appropriate revenue code,” he says.

The RFI expands on this issue and how it may have affected payment rates and puts forth options for potentially updating payment rates for 2025. There are several important points in the RFI, Settlemyer says. First, CMS reaffirms that providers are responsible for reporting the most appropriate revenue codes on claims. Second, CMS acknowledges that the RTP edit may have artificially impacted historical claims and resulting cost and APC calculations. And finally, CMS conducted an analysis of how the use of a cardiology revenue code may have elevated the geometric mean cost for the impacted codes and, therefore, the payment rate.

“I would encourage providers to thoughtfully consider and respond to this RFI,” Settlemyer says. “Are there other revenue code options or considerations? What and where are the preponderance of resources attributable to perform CT/CTA with all the elements contained in the CPT long description?”

CMS is specifically seeking feedback on:

• Where cardiac CT services are performed
• Factors involved in revenue code assignment for cardiac CT services
• What revenue codes hospital outpatient departments reported for cardiac CT services in 2024

See p. 223 of the proposed rule for CMS’ detailed questions.

New CoPs

CMS is proposing to establish new CoPs for hospitals and critical access hospitals for obstetrical services, as part of the administration's goal of addressing the maternal health crisis. The new requirements would include quality assessments and performance improvement, standards of care, staff training requirements on evidence-based maternal health practices, and more. CMS is also proposing to revise the emergency services CoPs and the discharge planning CoPs. The agency is seeking comment on whether these proposals should also apply to rural emergency hospitals.

Non-opioid pain relief

CMS is proposing to make additional payment for certain non-opioid pain relief items, including seven drugs and one device. This proposal would implement provisions of the Consolidated Appropriations Act (CAA) of 2023 which provides temporary additional payment for some non-opioid pain relief options. The proposal covers evidence requirements for medical devices and FDA-approved indications along with payment information.

Per statutory limitations, payments cannot be more than the estimated 18% average OPPS payment for the service or group of services the non-opioid treatment is provided with. Therefore, CMS is proposing to calculate the payment limitation based on the top five OPPS procedures by volume for each non-opioid drug or device. The agency is also proposing to assign a zero dollar payment offset for qualifying non-opioid drugs or devices.

Currently, separate payment for these treatments is only available in ambulatory surgical centers (ASC). The treatments are extremely effective, but their high cost has led to underutilization, says NAHRI Advisory Board member Ronald Hirsch, MD, FACP, ACPA-C, CHRI, vice president of the regulations and education group at R1 RCM Inc., in Murray, Utah.

“For revenue integrity professionals, when separate payment is established for a treatment that was previously bundled, it is important to review the chargemaster entry to ensure pricing is accurate and to ensure that when used there is a mechanism to capture that for inclusion as a line item on the claim,” he says.

Remote services

CMS is proposing a clarification on requirements for payments for OPPS-billable services furnished remotely to individuals in their homes. According to the proposal, the agency is planning to align these requirements with those in the Medicare Physician Fee Schedule covering telehealth.

Other proposals

Numerous other proposals address:

• Intensive Outpatient Program payment
• Payments to Indian Health Service and Tribal hospitals
• Coverage of services for individuals returning to the community after incarceration
• Quality reporting programs

More details on all proposals can be found in the proposed rule, as well as the accompanying fact sheet.

Revenue integrity professionals should carefully read the proposed rule. Focus on the proposals that would directly impact your organization, community, department, and specific job duties. Discuss the proposals with your revenue integrity colleagues as well as your peers in other departments who may be impacted.

Commenting on proposed rules is a crucial way to advocate for improvements that will benefit your community and protect the Medicare Trust Fund. Consider commenting on one or more proposals and responding to CMS’ direct requests for feedback in the proposed rule by the September 9 deadline. For guidance on how to write and submit an impact comment, use NAHRI’s white paper Advocacy in Action: Commenting on Proposed Rules.