News: CMS releases CY 2026 OPPS proposed rule

The calendar year (CY) 2026 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule, released on July 15, details payment updates, services covered, outpatient service volume, and quality reporting, among other proposals, according to JustCoding.

Inpatient only (IPO) list

Considering the “evolving nature of the practice of medicine” in which physicians can perform more procedures on an outpatient basis, CMS proposes phasing out the IPO list over a three-year period. The phase out would begin in CY 2026 with the removal of 285 mostly musculoskeletal procedures. Medicare would pay for services removed from the IPO list in outpatient hospital settings when clinically appropriate.

Controlling unnecessary increases in outpatient services volume

CMS proposes expanding the policy it adopted in the CY 2019 OPPS/ASC final rule to control unnecessary volume increases of clinic visit services furnished in excepted off-campus provider-based departments (PBD). The policy prevents Medicare and beneficiaries from paying significantly more for some services provided in excepted off-campus PBDs than in a physician office. The proposed expansion would add drug administration services furnished in excepted off-campus PBDs to the policy.

The agency estimates expanding this policy would reduce OPPS spending by $280 million in CY 2026, $210 million of which would be savings accrued to Medicare and $70 million in reduced beneficiary coinsurance saved by Medicare beneficiaries.

Quality reporting

CMS is proposing the adoption of the electronic clinical quality measure (eCQM) for Emergency Care Access and Timeliness for the hospital Outpatient Quality Reporting (OQR) program. The program requires hospital outpatient departments to report data on quality measures specified by CMS. Voluntary reporting for this quality measure would begin for the CY 2027 reporting period. Mandatory reporting would then begin with the CY 2028 reporting period/CY 2030 payment determination.

Contingent on the Emergency Care Access and Timeliness eCQM being finalized as proposed, CMS is also proposing the removal of the following:

• The Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients (Median Time for Discharged ED Patients) measure
• The Left Without Being Seen measure, beginning with the CY 2028 reporting period/CY 2030 payment determination

The agency is also proposing the removal of four other quality measures from the OQR program:

• The COVID-19 Vaccination Coverage Among Healthcare Personnel measure beginning with the CY 2024 reporting period/CY 2026 payment determination
• The Hospital Commitment to Health Equity (HCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination
• The Screening for Social Drivers of Health (SDOH) measure beginning with the CY 2025 reporting period
• The Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period

Like its proposal for the hospital OQR, CMS is proposing that the Rural Emergency Hospital Quality Reporting (REHQR) program also adopt the Emergency Care Access & Timeliness eCQM beginning with the CY 2027 reporting period/CY 2029 program determination as an optional measure. The measure would be an alternative to the Median Time from ED Arrival to ED Departure for Discharged ED Patients measure.

The agency is also proposing the removal of the following measures from the REHQR program:

• The HCHE measure beginning with the CY 2025 reporting period/CY 2027 payment determination
• The Screening for SDOH measure beginning with the CY 2025 reporting period
• The Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period

For the Ambulatory Surgical Center Quality Reporting (ASCQR) program, CMS is proposing the adoption of the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance measure. First with voluntary reporting beginning with the CY 2027 reporting period, then with mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination.

The agency is also proposing the removal of the following measures for the ASCQR program:

• The COVID-19 Vaccination Coverage Among Healthcare Personnel measure beginning with the CY 2024 reporting period/CY 2026 payment determination
• The Facility Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 payment determination
• The Screening for SDOH measure beginning with the CY 2025 reporting period
• The Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period

Payment rates and comment period

CMS proposes increasing OPPS payment rates by 2.4% in CY 2026 for hospitals and ASCs that meet applicable quality reporting requirements.

CMS encourages the public to comment on the proposed rule. The comment period ends September 15. For more information on the proposals and to submit a comment, see the Federal Register.

Editor’s note: This article was originally published in JustCoding.