CMS Issues 2025 Payment Policies for Outpatient Hospital Departments

November 19, 2024

The Centers for Medicare & Medicaid Services (CMS) issued the Outpatient Prospective Payment System (OPPS) final rule [PDF], which includes a 2.9% payment update for hospital outpatient departments (HOPDs) in 2025. This is an increase of $4.7 billion over 2024 payments to the sector, making total payments to HOPDs in 2025 an estimated $87.7 billion.

This rule primarily impacts audiologists because their services are paid through the OPPS, whereas most speech-language pathology services provided in this setting are exempt from the OPPS and paid under the physician fee schedule.

Learn more about the other proposals outlined in the rule below, including updates on:

Telehealth for Audiology and Speech-Language Pathology Services

In 2023, CMS generated significant concern about coverage for telehealth services provided by speech-language pathologists (SLPs) in HOPDs by providing a different interpretation for the continuation of telehealth flexibilities than other Part B settings in 2023 and beyond.

Thanks to extensive advocacy by ASHA and other stakeholders, CMS finalized a policy for 2023 and 2024 that would allow HOPDs to continue billing for telehealth services as they had during the COVID-19 public health emergency. This essentially leaves telehealth coverage unchanged through the end of this year.

In this rule, CMS states it will align telehealth coverage policies for speech-language pathology services provided in HOPDs with those under the physician fee schedule to provide continuity of Part B coverage policies across settings. Unfortunately, because audiology services provided in HOPDs are paid under the OPPS and not the fee schedule, this flexibility will not extend to audiology services. However, formalizing this policy will ensure HOPD patients receiving speech-language pathology services via telehealth can continue to do so as long as it’s allowed under state and federal law.

Next Steps for ASHA: While ASHA is pleased CMS finalized this policy, Congress still needs to ensure access to telehealth services provided by audiologists and SLPs beyond 2024. We will continue to push Congress to allow audiologists and SLPs to provide telehealth services permanently.

What You Can Do: The flexibility to cover audiology and speech-language pathology under the fee schedule will expire at the end of 2024 without congressional action. Please contact your members of Congress and encourage them to allow audiologists and SLPs to continue billing for telehealth services permanently.

Take Action for Telehealth Services

For more information on Medicare coverage of audiology and speech-language pathology telehealth services, please visit ASHA’s website.

Request for Information on Cost of and Payment Adjustments for Personal Protective Equipment (PPE)

CMS currently provides a payment adjustment to help hospitals offset the cost of PPE, particularly N95 respirators. In the proposed rule, CMS sought feedback on if it should allow additional forms of PPE to qualify for this payment adjustment, such as nitrile gloves. ASHA requested CMS also consider face shields (which are particularly appropriate for instrumental swallow studies) and clear face masks (to help individuals who may read lips as part of their communication strategies) to the list of items CMS provides payment adjustments for.

Next Steps for ASHA: CMS suggested it would use the feedback it received to issue additional rulemaking in the future. ASHA will monitor this as it evolves.

Hospital Inpatient Quality Reporting (IQR) Program

The Hospital IQR Program is a pay-for-reporting quality program that incentivizes quality improvement and penalizes hospitals that do not submit quality data or meet program requirements. CMS will extend voluntary reporting of the core clinical data elements, Hospital-Wide Readmission, and Hybrid Hospital-Wide Standardized Mortality measures for an additional year for the performance period of July 1, 2024, through June 30, 2025. This impacts the FY 2027 payment determination for the Hospital IQR Program.

What You Can Do: Educate your facility on the direct link between audiology and speech-language pathology services and reduced hospital readmission and mortality outcomes. Here are a couple helpful resources:

Hospital Outpatient Quality Reporting (OQR) Program

The Hospital OQR Program is a pay-for-reporting quality program for hospital outpatient departments that requires hospitals to meet quality reporting requirements. If they don’t meet the requirements, they are penalized with a 2% reduction in their annual payment update.
CMS will remove two measures related to low back pain and cardiac imaging and adopt four new measures:

Hospital Commitment to Health Equity measure, beginning with the 2025 reporting period/2027 payment determination
Screening for Social Drivers of Health (SDOH) measure, beginning with voluntary reporting in the 2025 reporting period followed by mandatory reporting beginning with the 2026 reporting period/2028 payment determination
Screen Positive Rate for SDOH measure, beginning with voluntary reporting in the 2025 reporting period followed by mandatory reporting beginning with the 2026 reporting period/2028 payment determination.
Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance measure (Information Transfer PRO-PM), beginning with voluntary reporting in the 2026 reporting period followed by mandatory reporting beginning with the 2027 reporting period/2029.

ASHA supports measures that ensure health equity and SDOH are appropriately recognized as impacting outcomes and cost of care for patients. Audiologists and SLPs can screen clients for SDOH in several ways:

Build SDOH-related questions into intakes and case histories.
Employ a formal SDOH screening tool or questionnaire.
Initiate conversations about SDOH with clients.
Note SDOH information shared by your client’s care team.
Review available documentation.

ASHA has developed resources to assist our members in collecting SDOH information.

Lastly, CMS finalized a requirement that electronic health record technology be certified to all Electronic Clinical Quality Measures (eCQMs) in this program to ensure that hospitals can accurately capture and report data for all eCQMs in the measure set.

Medicaid Changes to Maintain Continuous Eligibility

CMS finalized a change related to continuous eligibility for children 19 and under who are covered by Medicaid to implement a requirement of the Consolidated Appropriations Act of 2023. As a member of the Connecting to Coverage Coalition, ASHA advocated for the legislative changes CMS finalizes in this rule. Specifically, the new regulations require 12 months of continuous eligibility.

For example, if a child qualified for Medicaid on July 1, 2024 and then no longer met the state Medicaid eligibility requirements in December 2024, the child would remain on Medicaid until June 30, 2025. In addition, CMS will no longer allow eligibility for a child under the age of 19 to be revoked for failure to pay premiums during the 12-month period of eligibility. ASHA is pleased with these changes, which are a positive and significant step toward maintaining access to and continuity of care for children covered under Medicaid.

Changes to Prior Authorization Policies

Current regulations require that HOPDs seek prior authorization from Medicare Administrative Contractors (MACs) for select services, including botulinum toxin injections. Under the policy, MACs have 10 business days to respond to non-urgent requests and two business days to respond to expedited requests. However, in a separate final rule associated with interoperability and prior authorization requirements, CMS set prior authorization determinations at seven calendar days and within 72 hours for expedited requests.

CMS finalized these changes to align the non-urgent request determination timelines for HOPDs with those outlined in the interoperability and prior authorization final rule from 10 business days to seven calendar days. This should improve HOPD prior authorization requests so that patients can receive medically necessary care more quickly.

However, it is not changing the timeframe for expedited requests because in some cases two business days means the decision will come more quickly than 72 hours, whereas in other cases 72 hours is faster than two business days. For example, an expedited request made on Friday might be made faster under the 72-hour timeframe than the two-business-day timeframe. But requests made during the week would be made more quickly under the two-business-day timeframe.

Changes to the Ambulatory Payment Classifications (APCs)

ASHA analyzed the proposed APCs that include audiology codes and found no APC category changes for 2025. However, in its analysis of the final rule, ASHA noted a slight positive adjustment to APC groups, which includes audiology procedures. This increase is based on recent claims and cost report data analysis not available at the time the proposed rule was released, as well as changes to medical practice and technology.