CCA's 2025 CMS Prospective Rate Analysis

The 2025 CMS Proposed PFS and OBL Rates were released in July 2024. The 2025 rates will be finalized in October for Jan 2025 implementation and are subject to change. The following are the key takeaways pertaining to the services lines supported in CCA’s facilities. Rates are the national average.

• The CMS shift from office to ASC setting for PAD Interventions is resounding, and poses an existential threat to the OBL market while championing the ASC model. The office based PAD rates were reduced 5% on average while ASC rates increased 5% on average. With increasing prior auth scrutiny and reduced rates, can OBLs survive?
  • Femoral/Popliteal revascularization w/atherectomy (37225) increases 4% in ASC ($12,202) while decreasing 6% in the OBL ($7,926)
  • Iliac Revascularization w/Stent (37221 ) $7,091 increases 5% in the ASC while decreasing 5% in the OBL ($2,809).
• Cardiac Catheterization and PCI receive moderate uplifts in the ASC but further decreases in the OBL furthering the argument of an overall CMS site of services strategy shift for endovascular procedures to the ASC.
  • Example #1: Left Heart Catheterization (93458) increases 1% in the ASC($1,648) while OBL rates decrease 4% to ($966).
  • Example #2: PCI w/DE Stent (C9600) increase 4% in the ASC( $6,979) and is not payable in the OBL
• CRM Device Rates largely remained unchanged on average; resulting in a real net decrease compared to inflation; however these rates remain competitive and reasonable for care in the ASC Setting. CRM devices are not paid in the OBL.
• Cardiac Ablations are now being done for commercial payers at CCA sites but remained the primary disappointment from the ASC perspective as CMS limited CPT additions to the ASC fee schedule and none for Cardiology.
  • CCA, ASCA, HRS, and ACC all advocate for the inclusion of Cardiac Ablations and other appropriate procedures. CMS remained silent on these new procedures. The door is still open for October.
• The ASC procedure list expansion outlook for 2025/26 and beyond is likely politically dependent.
  • CMS dictates what procedures are covered in the ASC for Medicare beneficiaries. The RNC Project 2025 plan specifically advances the concept of expanding the ASC covered list thus paving the way for Ablations and other common sense procedures “regulations should advance site neutrality by eliminating the inpatient-only list and expanding the ambulatory surgical center covered procedures list”.