CMS issues payment fixes, updates to reimbursement and more in 2025 OPPS final rule
CMS gave the green light to improved payments for high-cost radiopharmaceuticals and made changes to its payment calculation for cardiac CT services among other updates in the 2025 Outpatient Prospective Payment System (OPPS) final rule.
The final rule, released November 1, includes changes to payments for outpatient hospital services, billing and coding updates, adjustments to quality and reporting programs, and more.
For 2025, CMS finalized a 2.9% payment increase, compared to a 2.8% increase in the proposed rule.
Unbundling radiopharmaceuticals
CMS finalized its proposal 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. Starting in 2025, CMS will remove the cost of these specific radiopharmaceuticals from the payment for the test.
Cardiac CT fix
CMS included a request for information (RFI) in the proposed rule to address an issue with revenue code assignment for cardiac CT services that may have affected payment. The agency stated 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.
An erroneous return-to-provider (RTP) edit was improperly limiting the revenue codes that could be reported with these services, according to the January 2024 OPPS update. Although CMS implemented a correction, because the edit ultimately affected data that the agency used to set payment rates, it issued the RFI to seek feedback on how best to address payments in 2025.
For 2025 and in subsequent years, CMS will use an alternative methodology to calculate payment for cardiac CT services and is finalizing a temporary reassignment of the cardiac CT codes (Current Procedural Terminology [CPT®] code 75572-75574) to Ambulatory Payment Classification (APC) 5572 (Level 2 Imaging with Contrast). Based on comments it received in the proposed rule, CMS anticipates that it will take several years to see an impact from changes in billing practices. Therefore, the agency anticipates using this alternative methodology until it has enough data. If, after three or four years, CMS does not see a significant increase in the geometric mean costs of these services based on claims data, it will revert payment for these services to the standard OPPS payment methodology and assign the cardia CT codes to the appropriate APCs based on their geometric mean costs.
See p. 324 of the final rule for more detailed information.
Payment for non-opioid pain relief
CMS finalized its proposal to implement provisions of the Consolidated Appropriations Act (CAA) of 2023 which provides temporary additional payment for some non-opioid pain relief options.
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 will calculate the payment limitation based on the top five OPPS procedures by volume for each non-opioid drug or device.
Other changes
The final rule addresses numerous other changes to Conditions of Participation (CoPs), billing, coding, quality and reporting programs, and more. Some of these changes include:
- New obstetrical CoPs
- Intensive Outpatient Program payment
- Coverage of services for individuals returning to the community after incarceration
- Quality reporting programs
Revenue integrity professionals should read the final rule carefully. Make note of provisions that may directly affect your job duties, department, and organization. Work closely with IT and clinical departments to ensure that systems are updated and tested prior to January 1, 2025. Discuss the changes with colleagues in other affected departments, including clinical departments and other revenue cycle departments. Ensure staff receive any necessary education and partner with departments such as HIM and clinical documentation integrity to make sure that education is complete and consistent.