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Today, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates proposed rule, along with an accompanying fact sheet. The rule has a 60-day comment period, and ASCRS will be providing comments.
ASC Conversion Factor
For CY 2025, CMS proposes to adjust the CY 2024 ASC conversion factor ($53.514) by the proposed wage index budget neutrality factor of 0.9958 in addition to the proposed productivity-adjusted hospital market basket update of 2.6%, which results in a proposed CY 2025 ASC conversion factor of $54.675 for ASCs meeting the quality reporting requirements.
For ASCs not meeting the quality reporting requirements, CMS is proposing to adjust the CY 2024 ASC conversion factor ($53.514) by the proposed wage index budget neutrality factor of 0.9958 in addition to the proposed quality reporting/productivity-adjusted hospital market basket update of 0.2%, which results in a proposed CY 2025 ASC conversion factor of $53.609 for ASCs not meeting the quality reporting requirements.
Estimated Impact of Proposed CY 2025 Update to ASC Payment System on Aggregate Payment for Cataract Surgery (66984)
Table 133 shows the estimated impact of the updates to the revised ASC payment system on aggregate ASC payments for selected surgical procedures, including 66984, during CY 2025. The proposed ASC payment rate for cataract surgery, CPT 66984, is estimated to increase by 2% of the CY24 payment rate of $1,329.00.
Non-Opioid Treatments for Pain Relief to be Paid Separately in Both the ASC and HOPD Settings Starting in CY 2025
Previously, CMS finalized a policy that non-opioid pain management drugs or biologicals that function as a supply in a surgical procedure are eligible for separate payment if the drug or biological does not have transitional pass-through payment status, and is not already separately payable in the OPPS or ASC payment system under a different policy. As a result, Omidria (J1097) and Dextenza (J1096) have been receiving separate payments in the ASC setting.
CMS now proposes implementing section 4135 of the Consolidated Appropriations Act of 2023, which provides temporary additional payment for certain non-opioid treatments for pain relief in the hospital outpatient department and ASC settings from January 1, 2025, through December 31, 2027. CMS proposes to implement these statutory provisions, including evidence requirements for medical devices and FDA-approved drug indications. In addition, to implement the statutory payment limitations under which the additional payment may not exceed an estimated 18% of the OPPS payment for OPPS service or group of services with which the non-opioid treatment is provided, CMS proposes utilizing the top five OPPS procedures by volume of each non-opioid drug to calculate the payment limitation. CMS is proposing to initially assign a payment offset of zero dollars for the qualifying non-opioid products, as maintaining the non-opioid portion of the procedure payment rate better aligns with the overall intent of the non-opioid policy.
Under these provisions, CMS is proposing six drugs and one device to qualify as non-opioid treatments for pain relief. These products are to be paid separately in both the HOPD and ASC settings starting in CY2025, including Omidria (J1097) and Dextenza (J1096). Proposed payment limitations for these two drugs are:
- Omidria (J1097) payment limitation: $383.59
- Dextenza (J1096) payment limitation: $386.39
Refer to Table 84 and 85.
ASC Quality Reporting (ASCQR) Program
The ASCQR Program is a pay-for-reporting quality program for the ASC setting. The ASCQR Program requires ASCs to meet program requirements or receive a reduction in their annual fee schedule update.
CMS is not proposing any changes to the Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (ASC-11) measure, which will remain voluntary in 2025. ASCRS strongly opposes the inclusion of this measure and will continue to work to ensure that the reporting does not become mandatory in the future.
CMS is also proposing the addition of the following three health equity-focused measures to the ASCQR in 2025:
- Facility Commitment to Health Equity (FCHE)
- Mandatory
- Assesses 5 domains and is similar to the existing Hospital Commitment to Health Equity (HCHE) measure.
- Screening for Social Drivers of Health (SDOH)
- Voluntary for 2025, Mandatory beginning in 2026
- This measure is similar to the MIPS measure of the same name (measure 487), with the only major difference being the site of service limited to ASCs.
- Screen Positive Rate for SDOH
- Voluntary for 2025, Mandatory beginning in 2026
- Using the results of the SDOH screens, report 5 separate performance rates (1 rate for each health-related social needs domain surveyed under the screening measure).
Finally, CMS is evaluating whether or not to make ASCQR reporting more specialty-focused in future years so that ASCs do not have to report on measures that are either not relevant or are minimally relevant to the care provided in their facility. CMS is requesting feedback. This is not a proposal but may appear in next year’s rule, based on the feedback received.
For questions about the proposed rule, please contact ASCRS Associate Director of Government Relations, Amanda Wiegrefe at [email protected]
More information will be detailed in upcoming editions of Washington Watch Weekly.
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