What’s Next for the OPPS: A Look at the 2025 Final Rule

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What’s Next for the OPPS
A Look at the 2025 Final Rule

Disclaimer Statement
This webinar/presentation was current at the time it was published or provided
via the web and is designed to provide accurate and authoritative information
regarding the subject matter covered. The information provided is only
intended to be a general overview with the understanding that neither the
presenter nor the event sponsor is engaged in rendering specific coding advice.
It is not intended to take the place of either the written policies or regulations.
We encourage participants to review the specific regulations and other
interpretive materials, as necessary.

Jennifer Bishop
RHIT, CCS, CCS-P, CHRI

Updates Affecting OPPS Payment

 Final 2025 OPPS Conversion Factor of
$89.169 – Up from $87.382 for 2024
 Predicted increase of 3.2% in OPPS
payments to providers
 The 2% reduction will still apply to
hospitals not meeting quality reporting
requirements – CF of $87.439
 The 7.1% adjustment for rural sole
community hospitals will continue
 Adjustment for cancer hospitals will
continue (payment-to-cost ratio equal to
0.88)

 Hospital outlier payments will be
triggered when a hospital’s cost of
furnishing a service exceeds 1.75x the
APC payment amount AND exceeds the
fixed dollar amount of $7,175 (down
from $7,750 for CY 2024)
 Outlier payments continue to be
calculated as 50% of the amount by
which the cost of the service exceeds
1.75x the APC payment amount

Updates to Packaging Policies

New Exclusions from C-APC Packaging
 Cell and Gene Therapies
 These therapies are independent from the other comprehensive procedures that may be
performed on the same date of service and should be reimbursed separately
 Non-Opioid Drugs, Biologicals and Devices for Pain Relief
 Qualifying items based on criteria for payment under the Consolidated Appropriations Act
of 2023, “Access to Non-Opioid Treatments for Pain Relief”

Excluded Cell and Gene Therapies
Trade Name Code Descriptor
Casgevy J3392 Injection, exagamglogene autotemcel, per treatment
Luxturna J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes
Zolgensma J3399 Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector
genomes
Yescarta Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 car positive viable T
cells, including leukapheresis and dose preparation procedures, per therapeutic dose
Kymriah Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis
and dose preparation procedures, per therapeutic dose
Provenge Q2043
Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF,
including leukapheresis and all other preparatory procedures, per infusion

Excluded Cell and Gene Therapies
Trade Name Code Descriptor
Tecartus Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t
Breyanzi Q2054 Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t
Abecma Q2055 Idecabtagene vicleucel, up to 510 million autologous B-cell maturation antigen (BCMA)
directed CAR-positive T cells, including leukapheresis and dose preparation procedures,
per therapeutic dose
Carvytki Q2056 Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen
(BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation
procedures, per therapeutic dose

Changes to Policy Packaged Drugs
 Diagnostic Radiopharmaceuticals exceeding per-day cost threshold of $630 will be
separately paid
 Calculations done based on 2023 claims data
 Annual packaging determination will be made
 Separately payable diagnostic radiopharmaceuticals will be subject to quarterly
reimbursement updates
 The threshold of $630 will be evaluated annually for updates
 Claims data will be used to calculate per-day costs, so make sure that costs are accurately
reported on claims
 Drugs that qualify will be given a status indicator of ‘K’

Qualifying Diagnostic Radiopharmaceuticals
A9515 - Choline C-11 A9572 – In-111 pentetreotide A9594 - Ga-68 PSMA-11 (UCLA)
A9521 – Tc-99m exametazime A9582 – I-123 iobenguance A9595 – Piflufolastate F18
A9542 – In-111 ibritumomab tiuxetan A9584 – I-123 ioflupane A9596 - Illuccix
A9547 – In-111 oxyquinoline A9586 – Florbetapir F18 A9602 – Fluorodopa F18
A9548 – In-111 pentetate A9587 – Ga-68 dotatate A9800 – Locametz
A9557 – Tc-99m bicisate A9588 – Fluciclovine F18 C9067 – Ga-68 dotatoc
A9568 - Arcitumomab A9591 – Fluoroestradiol F18 Q9982 – Flutemetamol F18
A9569 – Tc-99m A9592 – Copper Cu-64 dotatate Q9983 – Florbetaben F18
A9570 – In-111 labeled WBCs A9593 – Ga-68 PSMA-11 (UCSF)

Updates to OPPS APC-Specific Policies

Changes to New Technology APC Groups
HCPCS Description 2025 APC 2025 $ 2024 APC 2024 $
0662T
Scalp cooling, mechanical; initial measurement and
calibration of cap 1515 $1,751 1514 $1,251
0620T
Endovascular venous arterialization, tibial or peroneal vein,
with transcatheter placement of intravascular stent graft(s)
and closure by any method, including percutaneous or
open vascular access, ultrasound guidance for vascular
access when performed, all catheterization(s) and
intraprocedural roadmapping and imaging guidance
necessary to complete the intervention, all associated
radiological supervision and interpretation, when performed
1579 $35,001 1578 $27,501
G2083
Office or other outpatient visit for the evaluation and
management of an established patient that requires the
supervision of a physician or other qualified health care
professional and provision of greater than 56 mg
Esketamine nasal self-administration, includes 2 hours
post-administration observation
1516 $1,451 1520 $1,851

Cardiac CT Scans
75572 – Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology
75573 – Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology in the setting of
congenital heart disease
75574 - Computed tomographic angiography, heart, coronary
arteries and bypass grafts (when present), with contrast material,
including 3D image postprocessing
 Reassigned from APC 5571 (2024) to 5572 (2025)
 Status Indicator remains ‘S’
 Reimbursement change from $171 (2024) to $350 (2025)
 CMS corrected an old claims edit in December 2023 that was
likely preventing correct revenue code assignment for these
procedures

Laser Ablation of Prostate Cancer
0655T - Transperineal focal laser ablation of
malignant prostate tissue, including transrectal
imaging guidance, with MR-fused images or other
enhanced ultrasound imaging
 Reassigned from APC 5374 (2024) to 5375 (2025)
 Status Indicator remains ‘J1’
 Reimbursement change from $3,322 (2024) to
$5,084 (2025)

Bone Density Tests
 0743T - Bone strength and fracture risk using finite
element analysis of functional data and bone
mineral density (BMD), with concurrent vertebral
fracture assessment, utilizing data from a
computed tomography scan, retrieval and
transmission of the scan data, measurement of
bone strength and BMD and classification of any
vertebral fractures, with overall fracture-risk
assessment, interpretation and report
 Reassigned from status indicator M to S
 Assigned to APC 5523 for 2025 with payment rate
of $242
 The change in status indicators does not guarantee
coverage – MACs will be responsible for determining
eligibility and coverage requirements

3D Contour Simulation (CAS-One® IR)
 0944T - 3D contour simulation of target liver
lesion(s) and margin(s) for image-guided
percutaneous microwave ablation
 Reassigned from status indicator E1 to Q1
 Assigned to APC 5523 for 2025 with payment rate
of $242
 Will be bundled into procedure when reported with
another service with a status indicator of S, T, or V
 Adjunctive to percutaneous ablation therapy of liver
(47382)

Aqueous Shunt with Graft
66180 - Aqueous shunt to extraocular equatorial plate
reservoir, external approach; with graft
 Reassigned from APC 5492 (2024) to APC 5493
(2025)
 Status Indicator remains J1
 Reimbursement change from $3,874 (2024) to
$5,160 (2025)

CADScor® System
0716T – Cardiac acoustic waveform recording
with automated analysis and generation of
coronary artery disease risk score
 Remaining in APC 5733
 Status indicator changing from Q1 (2024) to S
(2025)
 Procedure is always provided in association with an
emergency department visit, so was effectively
always packaged with the ER visit

CardioMEMS™
 93264 – Remote monitoring of a wireless
pulmonary artery pressure sensor for up to 30
days, including at least weekly downloads of
pulmonary artery pressure recordings,
interpretation(s), trend analysis, and report(s) by a
physician or other qualified health care
professional
 Reassigned from Status Indicator M (2024) to Q1 (2025)
 Assigned to APC 5741 with reimbursement of $37 when
not reported with another significant procedure
 New HCPCS code G0555 – Provision of
replacement patient electronics system for home
pulmonary artery pressure monitoring - will be
assigned to APC 5724 with reimbursement of
$1,017

Complex Bunion Correction
28297 - Correction, hallux valgus with bunionectomy,
with sesamoidectomy when performed; with first
metatarsal and medial cuneiform joint arthrodesis,
any method
 Reassigned from APC 5114 (2024) to APC 5115 (2025)
 Status Indicator remains J1
 Reimbursement change from $6,816 (2024) to $12,867
(2025)

Dental Procedures
 Three dental codes reassigned from status
indicator B to J1.
– Services must be considered diagnostic and
treatment services medically necessary to eliminate
or eradicate an oral or dental infection prior to or at
the same time as certain Medicare-covered medical
services
– Reassignment of these procedures to a payable
status does not guarantee coverage, which must be
determined by the MAC
– Services would NOT be covered when done to
prepare a patient for dentures or dental implants,
which are not a Medicare-covered benefit

Dental Procedures
Code Description 2025 SI 2025 APC 2025 $$
D7320 Alveoloplasty not in conjunction with extractions –
four or more teeth or tooth spaces, per quadrant
J1 5163 $1,481
D7321 Alveoloplasty not in conjunction with extractions –
one to three teeth or tooth spaces, per quadrant
J1 5163 $1,481
D7471 Removal of lateral exostosis (maxilla or mandible) J1 5164 J1/5224

Digital Mental Health Treatment Devices
 G0552 – Supply of digital mental health treatment device and initial education and
onboarding, per course of treatment
 G0553 – First 20 minutes of monthly treatment management services directly related to the
patient’s therapeutic use of the DMHT device that augments a behavioral therapy plan
 G0554 – Each additional 20 minutes of monthly treatment management services directly
related to the patient’s therapeutic use of the DMHT device that augments a behavioral
therapy plan
 New technologies to help mitigate shortage of behavioral health professionals
 G0552 and G0553 will be assigned to APC 5012 with a national payment rate of approximately
$129

Drug-Coated Balloon for GI Tract Strictures
 0884T - Esophagoscopy, flexible, transoral, with initial transendoscopic mechanical dilation (eg,
nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter
for esophageal stricture, including fluoroscopic guidance, when performed
 Reassigned from APC 5303 with payment rate of $3,649 in 2024 to APC 5331 with payment rate of
$5,829 in 2025
 0885T - Colonoscopy, flexible, with initial transendoscopic mechanical dilation (eg, nondrug-
coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for colonic
stricture, including fluoroscopic guidance, when performed
 0886T - Sigmoidoscopy, flexible, with initial transendoscopic mechanical dilation (eg, nondrug-
coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for colonic
 Both reassigned from APC 5313 with payment rate of $2,675 in 2024 to APC 5331 with payment rate of
$5,829 in 2025

Hernia Repairs
 49593 - Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical,
spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh
or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible0885T -
Colonoscopy, flexible, with initial transendoscopic mechanical dilation (eg, nondrug-coated
balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for colonic
spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh
or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible
spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of
mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible
 Reassigned from APC 5341 with payment rate of $3,296 in 2024 to APC 5342 with payment rate of $5,835 in 2025

Implantable Cardiac Alert System
 0525T - Insertion or replacement of intracardiac
ischemia monitoring system, including testing of the
lead and monitor, initial system programming, and
imaging supervision and interpretation; complete
system (electrode and implantable monitor)
 Pass-through device associated with 0525T
expires 12/31/2024; CMS missed this and did
not include the device charges in the procedure
for 2025
 To correct this, 0525T is being reassigned from
APC 5223 to APC 5224
– Payment will increase from $10,174 to $19,071

Low Ejection Fraction AI-ECG Service
0764T - Assistive algorithmic electrocardiogram risk-based
assessment for cardiac dysfunction (eg, low-ejection fraction,
pulmonary hypertension, hypertrophic cardiomyopathy);
related to concurrently performed electrocardiogram
0765T - Assistive algorithmic electrocardiogram risk-based
assessment for cardiac dysfunction (eg, low-ejection fraction,
pulmonary hypertension, hypertrophic cardiomyopathy);
related to previously performed electrocardiogram
 Device approved by FDA in September 2023
 Qualifies for SaaS add-on codes policy
 Assigned to APC 5734 with reimbursement of $129 for
2025

Remote Uroflowmetry Service
 0812T - Remote multi-day complex uroflowmetry
(eg, calibrated electronic equipment); device
supply with automated report generation, up to 10
days
(2025)
 Status indicator remains Q1
 Reimbursement change from $36 (2024) to $156
(2025)

Aquadex SmartFlow System
 0692T – Therapeutic ultrafiltration
(2025)
 Status indicator remains S
 Reimbursement change from $414 (2024) to $1,639
(2025)

Transcutaneous Magnetic Peripheral Nerve
Stimulation
 0766T – Transcutaneous magnetic stimulation by
focused low-frequency electromagnetic pulse,
peripheral nerve, with identification and marking
of the treatment location, including noninvasive
electroneurographic localization (nerve conduction
localization), when performed; first nerve
(2025)
 Status indicator changed from Q1 to S
 Reimbursement change from $149 (2024) to $311
(2025)

Transurethral Ultrasound Ablation (TULSA)
 55882 - Ablation of prostate tissue, transurethral,
using thermal ultrasound, including magnetic
resonance imaging guidance for, and monitoring
of, tissue ablation; with insertion of transurethral
ultrasound transducer for delivery of thermal
ultrasound, including suprapubic tube placement
and placement of an endorectal cooling device,
when performed
 New code replacing HCPCS code C9734
 APC 5377 with reimbursement of $12,992

OPPS Payment For Devices

Pass-Through Status for Devices
There are 2 devices whose pass-through status will expire in 2024.
HCPCS
Code
Long Descriptor Product Name Expiration
Date
C1832 Autograft suspension, including cell processing and application, and all
system components
RECELL® System 12/31/24
C1833 Monitor, cardiac, including intracardiac lead and all system
components (implantable)
AngelMed Guardian™ 12/31/24

There are 11 devices whose pass-through status expires in 2025, 2026, or 2027.
HCPCS
Code
Date
C1826 Generator, neurostimulator (implantable), includes closed feedback loop leads and
all implantable components, with rechargeable battery and charging system
Evoke® SCS System 12/31/25
C1827 Generator, neurostimulator (implantable), non-rechargeable, with implantable
stimulation lead and external paired stimulation controller
ViviStim® System 12/31/25
C1747 Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device
(insertable)
Ureterol™ 12/31/25
C1600 Catheter, transluminal intravascular lesion preparation device, bladed, sheathed
(insertable)
FLEX VP™ System 12/31/26
C1601 Endoscope, single-use (i.e. disposable), pulmonary, imaging/illumination device
(insertable)
Ambu® aScope™ 5 Broncho HD 12/31/26
C1602 Orthopedic/device/drug matrix/absorbable bone void filler, antimicrobial-eluting
(implantable)
CERAMENT® G 12/31/26
C1603 Retrieval device, insertable, laser (used to retrieve intravascular inferior vena cava
filter)
CavaClear IVC Filter Removal Laser
Sheath
12/31/26

There are 11 devices whose pass-through status expires in 2025, 2026, or 2027.
HCPCS
Code
Date
C1604 Graft, transmural transvenous arterial bypass (implantable), with all delivery system
components
DETOUR™ System 12/31/26
C1605 Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable
components), rate-responsive, including all necessary components for implantation
AVEIR™ DR Dual Chamber Leadless
Pacemaker System
6/30/27
C1606 Adapter, single-use (i.e. disposable), for attaching ultrasound system to upper
gastrointestinal endoscope
EndoSound Vision System™ 6/30/27
C8000
Support device, extravascular, for arteriovenous fistula (implantable)
VasQ™
Extrasvascular Support Device
9/30/27

There are 5 new devices with pass-through status on 1/1/2025.
HCPCS
Code
Long Descriptor Product Name
C1735 Catheter(s), intravascular for renal denervation, radiofrequency, including all single
use system components
Paradise® Ultrasound Renal
Denervation System
C1736 Catheter(s), intravascular for renal denervation, ultrasound, including all single use
system components
Symplicity Spyral™ Catheter
C1737 Joint fusion and fixation device(s), sacroiliac and pelvis, including all system
components (implantable)
iFuse Bedrock Granite™ Implant
System
C1738 Powered, single-use (i.e. disposable) endoscopic ultrasound-guided biopsy device Precision GI
C9610 Catheter, transluminal drug delivery with or without angioplasty, coronary, non-
laser (insertable)
AGENT™ Paclitaxel-Coated Balloon
Catheter

Device Intensive Status
CMS has re-evaluated several procedures and determined that they should qualify as device-
intensive procedures
 C9757 – Laminotomy with decompression and repair of annular defect with
implantation of bone anchored annular closure device, lumbar
 52284 – Cystourethroscopy with urethral dilation and therapeutic drug delivery for
male stricture/stenosis
 0884T-0886T – GI tract dilation and drug delivery by drug-coated balloon catheter
 CMS declines to reinstate procedure-to-device edits at the current time so any device code will
satisfy the device-to-procedure edit
 Any procedure that has been deemed to be device intensive since January 1, 2017 will trigger
a device edit indefinitely

Device Offset Percentage Modification
 CMS has re-evaluated the process for determination of the device offset percentages
 Device offset percentage will be the greater of 31% or the device offset percentage of the
APC to which the procedure has been assigned when no claims data is available
 Device offset percentages will be calculated based on claims that reported a device code due
to concern that hospitals are not accurately reporting devices and device costs
 Claims data from procedures that were non-payable (status indicator E1) will not be used in
calculations
 Predecessor codes will be used in calculations when those exist

Drugs, Biologicals & Radiopharmaceuticals

Pass-Through Packaging Threshold
 Packaging threshold will increase to $140 for CY 2025 (up from $135 for 2024)
 Packaging determinations made once a year
 Based on 2nd Quarter 2024 ASP data from manufacturers
 Drugs without ASP information use mean unit cost derived from claims data
 There are 28 drugs and biologicals whose pass-through status will expire on 12/31/2024
– Status indicator will change from G (Pass-through drugs) to either K (Non-pass-through
drugs) or N (Packaged items/services)
– Drugs with status indicator of K will continue to be reimbursed at a rate equal to ASP + 6%
(updated on a quarterly basis)
 There are 80 drugs with continuing pass-through status

Reports Available on Dashboard

APC Changes Information

Policy-Packaged Drugs, Biologicals, and
Radiopharmaceuticals
 Anesthesia
 Diagnostic radiopharmaceuticals
 Contrast agents
 Pharmacologic stress agents
 Skin substitutes
 Implanted biologics
 Postsurgical pain management

Proposal to Use Invoice Pricing for Drugs Lacking
Pricing Data
 For CY 2026 CMS will allow MACs to
use provider invoice amount to set a
payment rate for drugs above the
threshold amount without sales data
on which to base the payment
amount
 NUBC will need to create a value
code to allow this
 Invoice cost will be drug cost less
rebates, chargebacks, or post-sales
concessions

Reversal of Alternate Payment Methodology for 340B Drugs
CMS has finalized their remedy for 340B-acquired drug payment policy for CY 2018-
2022
 CMS is providing lump-sum payments to affected 340B providers
– Estimated that these providers received $10.6 billion less than they would have without the 340B policy
– Providers have received $1.6 billion of that already through reprocessed claims
 CMS is implementing a budget neutrality adjustment of 0.9691 to the OPPS conversion
factor for CY 2026 until an estimated $7.8 billion is offset (approximately 16 years)
– Providers not enrolled in Medicare until after January 1, 2018 will not have offset applied

Modifier Use for 340B Drugs
CMS continues to require modifier use for separately-payable drugs acquired
through the 340B Program for tracking of Part B inflation rebate
 Modifier JG may continue to be assigned through December 31, 2024, but will be
deleted at that time
 Modifier TB may be assigned by all providers as of January 1, 2024, but must be used as
of January 1, 2025 to identify all separately-payable drugs acquired through the 340B
Program
– No payment reduction will result from modifier use

Skin Substitute Products
 Skin substitute products that have been assigned A2xxx codes will be
automatically assigned to high-cost skin substitute group until cost data can be
obtained
 Four skin substitute products are being reassigned from low-cost to high-cost
group for CY 2025
 Q4216 – Artacent Cord, per sq cm
 Q4252 – Vendaje, per sq cm
 Q4262 – Dual layer Impax, per sq cm
 Q4268 – Surgraft FT, per sq cm

JW and JZ Modifiers
 New JZ modifier (Zero drug amount
discarded/not administered to any
patient)
 All claims with single-use vials will
require a modifier
 JW on a separate line to identify waste
 JZ on the same claim line to identify no
waste
 Claim edits implemented on October 1,
2023

Changes to Inpatient Only (IPO) List

Codes Added to IPO for CY 2025
Code Long Descriptor
0894T Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver
allograft following normothermic perfusion
0895T Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including
hourly physiological and laboratory assessments (eg, perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile
pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment)
0896T Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological
and laboratory assessments (eg, perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose,
biliary bicarbonate, lactate levels, macroscopic assessment) (List separately in addition to code for primary procedure)

One Code Removed from IPO List
 22848 - Pelvic fixation (attachment of caudal end of instrumentation to
pelvic bony structures) other than sacrum (List separately in addition to
code for primary procedure)
 Most outpatient departments are equipped to provide the service and is
related to codes that have already been removed from the IPO List
 Code is being reassigned from a status indicator of C to a status indicator of
N for CY 2025

Non-recurring Policy Changes

Remote Mental Health Services
Hospital staff may continue to provide remote mental health services
 Patient must be located at home – includes temporary shelters
 Provider must be appropriately licensed with the state
 Patients must have an initial in-person visit within 6 months and subsequent
visits every 12 months (New for 2025)
 Exception for patients with documentation that in-person visit would cause harm; hospitals must also
document that patient has regular source of general medical care
 Audio-only communication is acceptable, but hospital must have capability to
provide two-way, audio/video services

Remote Outpatient Therapies
Hospital staff may no longer provide remote services as of January 1, 2025
 Physical Therapy
 Occupational Therapy
 Speech-Language Pathology Services
 Diabetes Self-Management Training
 Medical Nutrition Therapy
 Legislation only expanded the range of practitioners eligible to furnish telehealth
services through the end of 2024

Telemedicine E/M CPT Codes
 CMS will not recognize the
new telemedicine E/M code
set created by the AMA for
2025
 CPT codes 98000-98016
 Assigned status indicator B

Supervision Requirements
 Cardiac Rehab (CR), Intensive Cardiac Rehab (ICR), and Pulmonary Rehab (PR) services
may meet the direct supervision requirement through audio-video real-time
communications technology through 12/31/2025
 Supervising practitioners for CR, ICR, and PR services have been expanded to include
nurse practitioners, physician’s assistants, and clinical nurse specialists
 The direct supervision of diagnostic services requirement will include the virtual
presence of the physician or nonphysician practitioner through audio-video real-time
communications technology through 12/31/2025

Changes to Coverage for Colorectal Cancer
Screening Services
 Barium enemas used for colorectal cancer screening deleted as of 12/31/2024 as
these services are no longer recommended for screening
 G0106 - Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
 G0120 - Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
 G0122 - Colorectal cancer screening; barium enema
 CT colonography will now be separately payable
 74263 - Computed tomographic (CT) colonography, screening, including image postprocessing
– Status indicator changing from E1 in 2024 to S for 2025 with APC assignment of 5523 and approximate
reimbursement of $242

Payment for HIV PrEP Drugs and Services
 HIV Pre-Exposure Prophylaxis (PrEP) covered under Medicare Part B as of
September 30, 2024 as part of a National Coverage Determination
 Includes coverage for HIV drugs, drug administration, HIV and hepatitis B screening, and individual counseling by physicians or certain
other healthcare providers
Code Descriptor 2025 SI 2025 $$
G0011 HIV PrEP counseling by MD or other QHP, 15-30 minutes M $0
G0012 Injection of HIV PrEP drug S $71.17
G0013 HIV PrEP counseling by clinical staff S $29.79
J0739 Injection, cabotegravir, 1 mg for use as HIV PrEP K $6.81
J0750 Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg, oral, for use as HIV PrEP K $4.87
J0751 Emtricitabine 200 mg and tenofovir alafenamide 25 mg, oral, for use as HIV PrEP K $77.82
J0799 FDA approved prescription drug, for use as HIV PrEP A 95% of AWP
Q0521 Pharmacy supply fee for HIV PrEP M $0

Miscellaneous Changes

Non-Opioid Treatments for Pain Relief
 Additional payments for non-opioid treatments will begin on January 1, 2025 and
will continue for three years
 Drugs will not be packaged into other outpatient services
 Drugs must have a label indication approved by the FDA to reduce postoperative
pain or produce postsurgical or regional analgesia without acting upon the body’s
opioid receptors
 Devices must be used to deliver a therapy to reduce postoperative pain or produce
postsurgical or regional analgesia; device must also be FDA approved and
demonstrated the ability to replace, reduce, or avoid opioid use

Non-Opioid Drugs Approved for Additional
Payment for 2025
Code Descriptor APC/SI $$
C9089 Bupivacaine, collagen-matrix implant, 1 mg 0762/K1 $0.85
J0666 Injection, bupivacaine liposome, 1 mg 0763/K1 $1.45
J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg 9308/K1 $117.14
J1097 Phenylephrine 10.16 mg/ml and Ketorolac 2.88 mg/ml ophthalmic
irrigation solution, 1 ml
9324/K1 $96.59
J1885 Injection, ketorolac tromethamine, per 15 mg 0764/K1 $0.68

Non-Opioid Treatments for Pain Relief
 Devices will be reimbursed based on hospital charges reduced by cost (similar to
devices with pass-through status)
 Payment amount is limited to 18% of a volume-weighted average of the primary
procedure payment rate

Non-Opioid Devices Approved for Additional
Payment for 2025
Code Descriptor APC/SI Payment
Limit
C9804 Elastomeric infusion pump (e.g., On-Q* pump with bolus), including
catheter and all disposable system components, non-opioid medical device
2048/H1 $2,284.98
C9806 Rotary peristaltic infusion pump (e.g., ambIT pump), including catheter and
all disposable system components, non-opioid medical device
2056/H1 $2,284.98
C9807 Nerve stimulator, percutaneous, peripheral (e.g., SPRINT peripheral nerve
stimulation system), including electrode and all disposable system
components, non-opioid medical device
2057/H1 $2,483.16
C9808 Nerve cryoablation probe (e.g., cryoICE, cryoSPHERE, cryoSPHERE MAX,
cryoICE cryoSPHERE, cryoICE cryO2), including probe and all disposable
system components, non-opioid medical device
2058/H1 $985.94
C9809 Cryoablation needle (e.g., iovera system), including needle/tip and all
disposable system components, non-opioid medical device
2059/H1 $255.85

Status Indicator Changes
 Two new status indicators
 H1 – Non-Opioid Medical Devices for Post-Surgical Pain Relief
 K1 – Non-Opioid Drugs and Biologicals for Post-Surgical Pain Relief
 Modification to existing status indicators
 K – Nonpass-Through Drugs and Nonimplantable Biologicals, Including Radiopharmaceuticals
– Removed the word ‘therapeutic’ from the phrase therapeutic radiopharmaceuticals
 A – Added language to the definition to include HCPCS code J0799
– C9399 and J0799 now treated the same with regards to reimbursement calculation
 J1 and J2 – Removed the full list of exclusions from the descriptor and added reference to Addendum J

Hospital Outpatient Quality Reporting Program

Measures Added for Reporting
 Hospital Commitment to Health Equity (HCHE) Measure
 Mandatory for CY 2025 reporting period
 Screening for Social Drivers of Health (SDOH) Measure
 Voluntary Reporting for CY 2025 – Mandatory for CY 2026
 Screen Positive Rate for SDOH Measure
 Patient Understanding of Key Information Related to Recovery After a Facility-Based
Outpatient Procedure or Surgery Patient Reported Outcome-Based Performance
Measure

Measures Removed for CY 2025 Reporting
 MRI Lumbar Spine for Low Back Pain Measure
 Designed to determine number of patients who received MRI prior to attempting more
conservative measures for low back pain
 Not found to contribute to improved patient outcomes
 Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery
Measure
 Designed to measure the number of patients undergoing SPECT cardiac imaging, CCT, or
stress MRI prior to ambulatory surgery
 Not found to improve patient outcomes

Finalized Hospital OCR Program Measure Set
Measure Name
Abdomen CT – Use of Contrast Material
Admissions and ED Visits for Patients Receiving Outpatient Chemotherapy
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Breast Cancer Screening Recall Rates
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (voluntary measure)
COVID-19 Vaccination Coverage Among HCP
Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults (voluntary reporting until 2027)
Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy
Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan
Interpretation Within 45 Minutes of ED Arrival
Screening for Social Drivers of Health (voluntary reporting until 2026)

Finalized Hospital OCR Program Measure Set
Measure Name
Hospital Commitment to Health Equity
Left Without Being Seen
Median Time from ED Arrival to ED Departure for Discharged ED Patients
OAS CAHPS
Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or
Surgery, Patient Reported Outcome-Based Performance Measure
Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery
Risk-Standardized Patient-Reported Outcome-Based Performance Measure Following Elective Primary Total Hip
Arthroplasty and/or Total Knee Arthroplasty in the HOPD Setting (voluntary reporting until 2028)
Screen Positive Rate for Social Drivers of Health (voluntary reporting until 2026)
ST-Segment Elevation Myocardial Infarction (STEMI) eCQM

for standard prior authorization requests changed from 10 business days to 7 calendar days
Change in Prior Authorization Timeframes

Questions?
Jennifer Bishop
hcwebinars@healthcatalyst.com

What’s Next for the OPPS: A Look at the 2025 Final Rule