The final rule contains an increase to the OPPS payment rate in the amount of 2.9 percent for hospitals that meet applicable quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.4 percent reduced by a 0.5 percentage point productivity adjustment.
Intensive Outpatient Program
The final rule addresses Medicare payment rates for intensive outpatient program (IOP) services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs). CMS will maintain the existing rate structure, with two IOP APCs for each provider type: one for days with three services per day and one for days with four or more services per day. For this 2025 rate setting, CMS is using the 2023 claims data and the latest available cost information from cost reports beginning three fiscal years prior to the year that is the subject of the rulemaking.
For 2025, CMS is maintaining the calculation of both hospital outpatient department and CMHC IOP payment rates for three services per day and four or more services per day based on cost per day using OPPS data that includes Partial Hospitalization Program (PHP) and non-PHP days.
Partial Hospitalization Program
The final rule maintains the existing rate structure, with two Partial Hospitalization Program (PHP) APCs for each provider type: one for days with three services per day and one for days with four or more services per day. Consistent with the OPPS, for this 2025 rate setting, CMS is using the 2023 claims data and the latest available cost information from cost reports beginning three fiscal years prior to the year that is the subject of the rulemaking.
For 2025, CMS is maintaining the calculation of both hospital outpatient and CMHC PHP payment rates for three services per day and four or more services per day based on cost per day using OPPS data that includes PHP and non-PHP days. CMS believes continuing to use the OPPS data set will allow CMS to capture data from hospital claims that are not identified as PHP but that include the service codes and intensity required for a PHP day.
Non-Opioid Treatments for Pain Relief
CMS is finalizing the implementation of Section 4135 of the Consolidated Appropriations Act (CAA), 2023, which provides temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) setting from January 1, 2025, through December 31, 2027. This policy implements several statutory provisions, including evidence requirements for medical devices and the requirements for the FDA-approved indications. To implement the statutory payment limitation, CMS is finalizing its proposal to utilize the top five OPPS procedures by volume, for each non-opioid drug or device, to calculate the payment limitation.
CMS is finalizing the policy to include drugs and devices that qualify as non-opioid treatments for pain relief, and these products will be paid separately in the HOPD setting, starting in 2025. The qualifying drugs have FDA-approved indications to reduce post-operative pain or produce postsurgical analgesia, and the qualifying medical devices have demonstrated through evidence that they reduce opioid usage when used in the post-operative setting.
High-Cost Diagnostic Radiopharmaceuticals
Under the OPPS, the payment for diagnostic radiopharmaceuticals is packaged into the payment for the nuclear medicine tests with which they are used. In some specific circumstances, the payment amount for the nuclear medicine tests may not adequately account for the cost of certain high-cost diagnostic radiopharmaceuticals, even when those agents may be the most clinically appropriate. Consequently, the final rule makes refinements to the existing packaging policy to improve the accuracy of the overall payment amounts by paying separately for any diagnostic radiopharmaceutical with a per day cost greater than $630 and removing their costs from the payment amounts for the nuclear medicine APCs.
All qualifying products will be paid separately at their mean unit cost (MUC), which is a payment rate derived from hospital claims data. Any diagnostic radiopharmaceutical with a per-day cost equal to or below that threshold will continue to be policy packaged, with payment for the nuclear medicine tests. This update should address challenges for patients in accessing these prescribed nuclear medicine tests with higher-cost radiopharmaceuticals.
Add-on Payment for Technetium-99m (Tc-99m)
Radioisotopes are widely used in modern medical imaging. Technetium-99m (Tc‑99m), the radioisotope used in most diagnostic imaging services, is historically derived from legacy reactors outside of the United States using highly enriched uranium (HEU). Beginning in 2013, CMS finalized a policy to provide an additional payment of $10 for the marginal cost of Tc-99m produced by non-HEU sources. 2025 is the final year of the add-on payment for Tc-99m when the Tc-99m is produced without the use of HEU.
However, the U.S. Department of Energy has identified another issue affecting the domestic supply chain for molybdenum-99 (Mo-99), the source material for Tc-99m, that could cause payment inequity among outpatient hospital providers. Foreign Mo-99 production has historically been subsidized by foreign governments, resulting in prices below the true cost of production. These artificially low, foreign government-subsidized prices have created a disincentive for domestic investments in Mo-99 production infrastructure and a barrier to entry for new producers. Accordingly, the rule finalizes the CMS proposal to address the payment inequity in this rule by establishing a new add-on payment, of $10 per dose, for radiopharmaceuticals that use Tc-99m derived from domestically produced Mo-99, starting on January 1, 2026.
Devices
In the 2023 OPPS final rule, CMS finalized a policy to make a single blended payment for devices and services in Category B Investigational Device Exemption (IDE) studies, in order to preserve the scientific validity of these studies by avoiding differences in Medicare payment methods that would otherwise reveal the group (treatment or control) to which a patient had been assigned.
CMS then proposed to extend its coding and payment policy to drugs and devices being studied in clinical trials under a Coverage with Evidence Development (CED) National Coverage Determination (NCD), for which the trial includes a treatment and control arm. Based on commenter feedback, CMS is not finalizing its proposal at this time. It believes that there are broader policy implications that require further consideration prior to finalizing a policy.