Release of 2025 OPPS Proposed Rule: Focuses on Payment Adjustments, Health Equity, and Maternal Health

Release of 2025 OPPS Proposed Rule: Focuses on Payment Adjustments, Health Equity, and Maternal Health

While CMS (the Centers for Medicare & Medicaid Services) usually releases new rules in the afternoon, on July 10 they chose to release the 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule before 9 a.m. At 984 pages, the rule contains the usual adjustments to payment rates for both hospital outpatient services and ambulatory surgery center care, along with more efforts to promote health care equity and improve maternal health.

From the utilization management side though, it is generally status quo. The rule makes no adjustments to the Two-Midnight Rule, adds only three seldom-used codes related to complex liver procedures to the inpatient-only list, removes no surgeries from the inpatient-only list, and add several surgeries to the ambulatory surgery center covered procedure list, most notably placement and removal of a leadless pacemaker.

As has been discussed on Monitor Mondays and Talk Ten Tuesdays, the Supreme Court overturn of Chevron Deference creates an environment where many of the policies followed by hospitals are potentially subject to challenge in the courts. Perhaps CMS felt it best to avoid any major changes for 2025 to maintain some degree of regulatory stability, at least for now.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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