On July 15, 2025, the Centers for Medicare & Medicaid Services (“CMS”) issued the CY 2026 Hospital Outpatient Prospective Payment System (“OPPS”) and Ambulatory Surgical Center (“ASC”) Payment System proposed rule. The rule, as drafted, proposes updating the fee charges of each OPPS hospital charges and ASC charges by 2.4%, calculated through the respective market basket share will increase of three.2% and lowered productiveness adjustment of 0.8 share factors. Regarding the ASC Covered Procedures List (“ASC-CPL”), the CY 2026 proposed rule is trying to make vital additions to the ASC-CPL, much like the CY 2021 OPPS/ASC ultimate rule, as defined under.
History of Added Procedures to the ASC-CPL and Exclusion Criteria
The CY 2021 OPPS/ASC ultimate rule made vital adjustments to each the ASC-CPL and the factors for including procedures to the record. That rule added 267 surgical procedures to the ASC-CPL, and CMS started to additional emphasize the judgment of physicians as to which procedures could be coated by Medicare when carried out in an ASC. The CY 2021 rule modified the factors that was beforehand used so as to add procedures to the ASC-CPL into situation-specific elements for physicians to contemplate in deciding whether or not a person ought to obtain protection for that exact process.
Then the CY 2022 rule considerably departed from the CY 2021 rule. The CY 2022 rule not solely reversed the factors adjustments made in CY 2021 by reinstating the CY 2020 standards for including procedures, nevertheless it additionally eliminated 255 of the 267 surgical procedures added simply the 12 months earlier than. The CY 2022 rule did, nevertheless, start a “nomination course of,” by means of which third events may recommend surgical procedures they believed each met the relevant standards and needs to be added to the ASC-CPL record.
Overview of Proposed Added Procedures to the ASC-CPL
The CY 2026 proposed rule appears to reflect the development of the CY 2021 rule in each the proposed additions to the ASC-CPL and the factors for including new procedures. The proposed rule suggests including 276 surgical procedures to the ASC-CPL and transferring 271 codes from the Inpatient Only Procedures List to the ASC-CPL, leading to a complete addition of 547 codes. Many of the additions are cardiovascular, vascular and backbone codes that had been beforehand added then eliminated between the CY 2021 and CY 2022 ultimate guidelines. Examples of the added procedures embody: electrophysiology research and ablations (93650, 93653, 93654, 93656); percutaneous coronary intervention (C9602, C9604, C9607); vascular embolization or occlusion (37244); posterior lumbar interbody fusion (22630); and mixed posterior lumbar and posterior lumbar interbody fusion (22633). A whole record of proposed added codes will be present in Tables 80 and 81 of the rule.
Similar to the CY 2021 rule, CMS has proposed to once more change the factors for including new procedures and codes to the ASC-CPL. The CY 2026 rule proposes remodeling 5 current exclusion standards into “nonbinding doctor concerns,” giving extra deference to the private judgment of physicians.
Additions to the ASC-CPL usually mirror each CMS’s, physicians’ and the general public’s beliefs about which procedures will be safely, successfully and effectively carried out in ASC settings. The proposed adjustments within the CY 2026 proposed rule appear to sign that each CMS and the general public need to enhance accessibility to surgical procedures within the lowest value setting potential, whereas nonetheless prioritizing affected person security. The CY 2026 proposed rule will not be solely trying to tremendously enhance the variety of procedures supplied in ASCs by means of the proposed additions to the ASC-CPL, however can also be trying to present physicians with extra say as to the procedures they consider will be carried out safely and effectively in ASCs.
For extra info on the CY 2026 proposed rule because it pertains to telehealth, see our earlier publication on Medicare’s Telehealth Proposals for CY 2026.
Practical Takeaways
- The enlargement of the ASC-CPL helps the development of transitioning as many procedures as will be carried out safely in an ASC from the hospital setting, a development which is overwhelmingly supported by surgeons, payors and most significantly, sufferers.
- Stakeholders ought to take into account submitting feedback on the proposed adjustments earlier than September 15, 2025, utilizing code CMS-1834-P.
- Consider when structuring ASC preparations, whether or not the addition of the brand new procedures might have an effect on physicians eligible to spend money on the ASC.
- Consider how the proposed added procedures might have an effect on your present system and plan for addressing these adjustments if the CY 2026 ultimate rule mirrors that of the proposed rule.
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Special due to Summer Associate Eleanor Hagenow for her help within the preparation of this text.