On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) proposed Medicare payment rates for hospital outpatient and Ambulatory Surgical Center (ASC) services. The Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule is published annually and will have a 60-day comment period, which will end on September 9, 2024. The final rule will be issued in early November.
In addition to proposing payment rates, this year’s rule includes proposed policies that align with several key goals of the Administration, including addressing health disparities, expanding access to behavioral health care, improving transparency in the health system, and promoting safe, effective, and patient-centered care. The proposed rule advances the Agency’s commitment to strengthening Medicare and uses the lessons learned from the COVID-19 PHE to inform the approach to quality measurement, focusing on changes that would help address health inequities.
These proposed payment policies would affect approximately 3,500 hospitals and approximately 6,100 ASCs. As with other rules, CMS is publishing this proposed rule to meet the legal requirements to update Medicare payment policies for OPPS hospitals and ASCs annually. This fact sheet discusses the major provisions of the proposed rule (CMS-1809-P), which can be downloaded at:Â https://www.federalregister.gov/documents/current.
A fact sheet includes the following imaging related proposals:
OPPS Proposal to Improve Payment for Specialized Diagnostic Radiopharmaceuticals
Under the OPPS, the costs associated with diagnostic radiopharmaceuticals are packaged into the payment for the nuclear medicine tests they are used with. While this payment approach generally works appropriately to support efficient care, we recognize that in some specific circumstances, the payment amount for the nuclear medicine tests may not adequately account for the cost of certain specialized diagnostic radiopharmaceuticals, even when those agents may be the most clinically appropriate. Consequently, we are proposing 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 tests. Any diagnostic radiopharmaceutical with a per-day cost equal to or below that threshold would continue to be policy-packaged, with costs incorporated into the payment rates 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 Domestically Produced 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 CY 2013, we finalized a policy to provide an additional payment of $10 for the marginal cost of Tc-99m produced by non-HEU sources.
CY 2025 is the final year of the add-on payment for Tc-99m when the Tc-99m is produced without the use of HEU, as the Secretaries of Energy and Health and Human Services have issued a certification that there is sufficient global supply of Tc-99m without the use of HEU available to meet the needs of patients in the United States.
However, the Department of Energy and other interested parties have 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. We propose to address this 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. We believe the $10 add-on payment for domestically produced Tc-99m would ensure equitable payments by paying providers who use domestically produced Tc-99m radiopharmaceuticals when available, an amount that reflects the anticipated higher cost of these products. The $10 add-on payment will help to preserve provider and individual access to domestically produced Tc-99m radiopharmaceuticals by addressing the additional cost of domestically produced Tc-99m radiopharmaceuticals.
For more information, visit https://www.cms.gov/newsroom/fact-sheets/cy-2025-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center
