The Centers for Medicare & Medicaid Services (CMS) on Nov. 1 released the calendar year (CY) 2025 Outpatient Prospective Payment System (OPPS) final rule. Unless otherwise specified, policies will be effective Jan. 1, 2025.
The CMS finalized a net 2.9% increase to the OPPS payment rate, derived from a 3.4% market basket increase minus a 0.5 percentage point productivity adjustment. The agency also finalized a proposal to establish an obstetrical (OB) services standard Conditions of Participation (CoP) and revised the emergency services and discharge planning CoPs. These changes to the CoP will be phased in over two years. In Phase 1, hospitals and critical access hospitals (CAHs) will be required to comply with changes to the emergency services CoP by July 1, 2025. However, only hospitals (not CAHs) are required to meet the revised discharge planning requirements in this phase. Phase 2 will require hospitals and CAHs to be in compliance with organization, staffing, and delivery of services elements of the new OB services CoP by Jan. 1, 2026. Hospitals will have until Jan. 1, 2027, to comply with the OB staff training and quality assessment program requirements.
The CMS finalized numerous additional policies within the final rule, including updating timeframes for the hospital outpatient department prior authorization process, maintaining intensive outpatient program and partial hospitalization program rate setting, improving access to non-opioid treatments for pain relief, and revising payment for specialized diagnostic radiopharmaceuticals. The agency also enacted changes to the definition of “custody” in Medicare's payment exclusion rule, to continuous eligibility for children in Medicaid and the Children’s Health Insurance Program, and to the Medicaid clinic services four walls exceptions.
The agency also finalized changes to requirements under the Inpatient Quality Reporting Program and the Outpatient Quality Reporting Program, as well as summarized responses to a request for information on emphasizing patient safety in the Overall Hospital Quality Star Ratings.