2025 OPPS Final Rule: Everything You Need to Know

When CMS released its 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule this summer, it signaled a sea change across four regulatory programs: OQR (outpatient), ASCQR (ASC), REHQR (Rural Emergency Hospital), and IQR (inpatient). Yes, even the IQR program wasn’t safe this go-round...

And now with the release of the 2025 OPPS Final Rule, it’s clear that CMS is not backing down from its ambitious plans. Virtually every proposed change has been adopted in this ruling, making it a significant leap forward in CMS’s mission to prioritize critical issues like patient safety and health equity across every patient-care setting.

If you’re already familiar with the proposed rule, then 99% of these final-rule decisions shouldn’t come as a shock to you. Read on to see what you need to know to get ready for the big changes that are just ahead.

General Program Updates for 2025

The Payment Rate Increase is Better than Expected

Good news: CMS has authorized a slightly-higher-than-expected increase in the payment rate for 2025. Originally proposed as a 2.6% increase, CMS has decided on a 2.9% increase instead. This translates to an Outpatient Department (OPD) fee schedule of $89.169 for applicable services.

Hospitals that fail to comply with the OQR program’s reporting requirements will, as promised, get hit with a 2% reduction in their payment rate updates, which equals out to an $87.439 OPD fee.

Also see: How does the OQR penalty work?

Health Equity Measures are Required Across the Board

CMS is moving forward with its decision to add health equity measures across every program listed under the final rule. These measures, which are already required in the IQR and IPFQR programs, will now also be required of OQR, REHQR, and ASCQR program participants. We’ve outlined the specific measures you’re now responsible for in each program summary below.

Also see: An intro to CMS’s SDOH measures

Conditions of Participation Are Changing

In its ongoing prioritization of maternal health, CMS has decided to adopt the long list of OB-centered Conditions of Participation (CoPs) that it proposed this summer. Hospitals and CAHs who offer OB services will have to adhere to these requirements or lose their Medicare contract. You can find a bulleted list of all your new CoPs later on in this blog.

Star Rating Modifications Are Still Under Consideration

In the proposed rule, CMS requested feedback on closing a loophole in the current Hospital Quality Star Rating methodology that allows hospitals who perform poorly in the Safety of Care measure group to still achieve a 5-star rating.

Based on comments it received, CMS is still considering three options for “future potential rulemaking”:

1. 1. Reweighting the Safety of Care measure group from 22 percent to 30 percent.
   2. Implementing a policy-based adjustment that reduces the Star Rating of any hospital in the lowest quartile of Safety of Care by one star.
   3. Combining the reweighting of the Safety of Care measure group with a policy-based cap that limits hospitals in the lowest quartile of Safety of Care (based on at least three measure scores) to a maximum of four stars out of five.

They also confirmed that they will continue to leave the door open to adding new eCQMs, such as the Severe Obstetric Complications and the Hospital Harm: Opioid-Related Adverse Events eCQMs, to the Safety of Care measure group. So, if your performance isn’t great on these measures, it’s time to start working on them.

Also see: The October 2024 Care Compare Refresh

OQR Program: 2025 Updates

New Information Transfer PRO-PM

The biggest news in the OQR Program is that CMS has signed off on a new PRO-PM, the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery Patient Reported Outcome-Based Performance Measure, or the Information Transfer PRO-PM for short.

This measure will track how patients rate the information you provide to them before, during, and after a surgery or procedure. Patient surveys, which can be issued directly by you or through a third-party vendor, must be administered between two to seven days post-surgery/procedure.

The measure’s denominator includes patients aged 18 or older who underwent a procedure or surgery in a hospital outpatient department (HOPD) and fully completed the survey. The numerator is the sum of all individual scores received from eligible respondents, using a top-box approach.

Hospitals must sample and submit 300 completed surveys. If the hospital doesn’t have 300 eligible cases, they must submit everything they’ve got.

Voluntary reporting starts January 1, 2026. Mandatory reporting starts January 1, 2027.

New Health Equity Measures

The same health equity measures you’re responsible for in the IQR Program are coming to the OQR Program. And while these measures will need to be submitted separately from their IQR counterparts, CMS understands that this could lead to a lot of unnecessary redundancies in screenings. Therefore, if a patient has been screened in one of your other care settings, you will be allowed to use that data to meet your OQR requirements, provided that the data was collected during the same reporting period.

• Hospital Commitment to Health Equity: required 2025
• SDOH-01 & SDOH-02: voluntary 2025, required 2026

Retired Measures

The MRI Lumbar Spine for Low Back Pain measure and the Cardiac Imaging for Preoperative Risk Assessment measure are officially out of the program in 2025.

Public Reporting Enhancement

The Median Time from ED Arrival to Departure for Discharged ED Patients measure will now be publicly reported on Care Compare, with a specific focus on your Psychiatric/Mental Health Patients stratification.

EHR Certification Requirement

Starting in 2025, CMS is requiring certified Electronic Health Record (EHR) technology (CEHRT) to be certified to all available OQR eCQMs.

IQR Program: 2025 Updates

Hybrid Measures Remain Voluntary for Now

As you probably gathered from the proposed rule, hybrid measure submissions aren’t going well. As such, CMS has confirmed that the hybrid measure reporting cycle that just wrapped (July 1, 2023 – June 30, 2024, Reporting Year 2024) will technically be re-classified as a voluntary—not mandatory—reporting period.

And while this information doesn’t do you much good now, CMS has thrown you a bone: it’s extending voluntary reporting for an additional year (July 1, 2024 - June 30, 2025, Reporting Year 2025). That makes the first mandatory reporting year July 1, 2025 – June 30, 2026.

Also see: 4 Lessons Learned from Hybrid Measure Submissions

REHQR Program: 2025 Updates

New Health Equity Measures

The same information from our OQR Program update applies here. The health equity measures are added to the program’s requirements.

• Hospital Commitment to Health Equity: required 2025
• SDOH-01 & SDOH-02: voluntary 2025, required 2026

Modified Measures

CMS is extending the reporting period for the Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery measure from one year to two years, starting in the CY 2027 program determination (January 1, 2024 – December 31, 2025).

Because REHs tend to have lower surgical volumes, this is intended to give them the time to accrue enough cases to meet the minimum case threshold of 30 surgical cases that’s needed for reliable measurement.

Data Submission Policy Modification

Are you working towards or have just earned REH designation? If so, CMS is now mandating that you must begin submitting data to the REHQR program on the first day of the quarter following the date your REH designation is awarded.

ASCQR Program: 2025 Updates

New Health Equity Measures

CMS has added essentially the same health equity measures to this program, too—with a slight variation. The Facility Commitment to Health Equity measure (FCHE) is almost identical to the HCHE measure in terms of its framework (the same 5 domains) and measure type (it’s an attestation measure, too). The one difference is that, under Domain 2: Data Collection, the FCHE measure does NOT require your EHR to be CERHT. You must still, however, attest to the use of EHR technology in general.

• Facility Commitment to Health Equity: required 2025
• SDOH-01 & SDOH-02: voluntary 2025, required 2026

Feedback on Proposed Specialty-Focused Reporting Frameworks

In the proposed rule, CMS asked for comments on two specialty-focused frameworks it’s considering for ASCs:

• Specialty-Select framework: ASCs would be required to report all specialty-specific, claims-based measures and select a specified number of the remaining non-claims-based specialty-specific measures (currently, five) to report.
• Specialty Threshold framework: ASCs would be required to report all specialty-specific, claims-based measures and report all non-claims-based specialty-specific measures for which case counts reach a specified case threshold minimum.

Based on the comments published in the final rule, it appears that the idea of a specialty-focused framework was met favorably, as it would reduce the reporting burden placed on ASCs while also improving the value of their quality reporting by enabling them to report only on the measures most applicable to them.

As for when we can expect to see any of these changes? CMS would only go so far as to say that it was under consideration for “future rulemaking.”

Table 173: Current Specialty Specific ASCQR Program Measures

Conditions of Participation (CoP): 2025 Updates

Overall, CMS has adopted every new Condition of Participation it proposed this summer, with some minor wording modifications sprinkled in (see the complete list below).

It has also decided not to extend these CoPs to REHs for the time being.

For hospitals and CAHs, however, it has agreed to take a 2-year phased approach to implementation, as follows:

Table 174: Implementation Timeframe for Hospitals and CAHs

If your hospital or CAH offers OB services

1. Adhere to these Organization, Staffing, and Delivery of Services Requirements

1. 1. Ensure obstetrical services are well-organized and provided in accordance with nationally recognized acceptable standards of practice for both physical and behavioral health care of pregnant, birthing, and postpartum patients.
   2. Ensure outpatient obstetrical services are consistent in quality with inpatient care based on the complexity of services offered.
   3. Organize obstetric services appropriately to the scope of services offered and integrate them with other departments of the facility.
   4. Supervise obstetrical patient care units by an individual with the necessary education and training, such as an experienced registered nurse, certified nurse midwife, nurse practitioner, physician assistant, or a doctor of medicine or osteopathy.
   5. Delineate obstetrical privileges for all practitioners providing obstetrical care and maintain a roster of practitioners specifying their privileges, all in accordance with medical staff bylaws and/or agreements for credentialing and quality assurance.
   6. Establish policies governing obstetrical care to ensure high standards of medical practice and patient care and safety.
   7. Equip labor and delivery room suites with basic equipment, including a call-in-system/call button, cardiac monitor, and fetal doppler or monitor, that’s readily available for treating obstetrical cases to meet the needs of patients.
   8. Implement protocols consistent with evidence-based, nationally recognized guidelines for obstetrical emergencies, complications, immediate post-delivery care, and other patient health and safety events, with necessary supplies and equipment readily accessible.
   9. Follow nationally recognized acceptable standards of practice for physical and behavioral health care of pregnant, birthing, and postpartum patients, based on medical professional society and/or accrediting organization standards.
   10. Articulate your standards, the sources of these standards, and demonstrate that they are based on evidence and nationally recognized sources.

2. Train Staff Using Evidence-Based Best Practices: Hospitals and CAHs must develop policies to ensure that obstetrical services staff are trained biannually on evidence-based best practices. Training must be documented and tailored to staff roles. The following elements must be in place effective January 1, 2027:

1. Develop policies and procedures that ensure obstetrical services staff are trained on evidence-based best practices and protocols to enhance maternal care.
2. Training Topics: Training should encompass trauma-informed care, cultural competency, and person-centered care. These topics should align with the scope and complexity of services provided and be informed by the facilities’ Quality Assurance and Performance Improvement (QAPI) programs. Participation in local or regional perinatal quality collaboratives (PQCs) and the implementation of patient safety bundles are also encouraged.
3. Initial & Ongoing Training The governing body must identify and document which staff must complete (1) initial training and (2) subsequent biannual training and document in the personnel records that the training was successfully completed.
4. Demonstration of Staff Knowledge: Facilities must demonstrate that staff have knowledge of the training topics, although the method of demonstration is not specified.
5. Continuous Improvement: Training needs and updates should be informed by findings from the facility’s QAPI programs.

3. Use Data to Drive Improvements to Maternal Health Outcomes

A. Data Analysis: Hospitals are already required to engage in quality activities to improve patient care and outcomes under the Quality Assessment and Performance Improvement (QAPI) program standards. Existing QAPI standards do not require that facilities analyze or stratify QAPI data by patient subpopulations such as race, gender, or payer. This proposal would modify the existing QAPI standards and require hospitals to use its QAPI program to assess and improve health outcomes and disparities among OB patients on an ongoing basis. Specifically, you must:

1. 1. • Analyze data and quality indicators collected for the QAPI program by diverse subpopulations among OB patients.
      • Measure, analyze, and track data, measures, and quality indicators related to patient outcomes and disparities in processes of care, services, operations, and outcomes among OB patients.
      • Analyze and prioritize patient health outcomes and disparities. You must develop and implement actions to improve these outcomes and disparities, measure the results, and track performance to ensure that improvements are sustained when disparities exist among OB patients.
      • Conduct at least one performance improvement project annually that focuses on improving health outcomes and disparities among the hospital’s population(s) of OB patients.
      • Leadership at your organization must be engaged in the facility’s QAPI activities.
      • If an MMRC (Maternal Mortality Review Commission) is available at your facility in the State or local jurisdiction, your hospital must have a process for incorporating MMRC data and recommendations into the facility’s QAPI program.

Note: CMS said you can use the PC-02 and PC-07 eCQMs to meet the data analysis portion of these requirements. And you can use the inpatient SDOH-01 and SDOH-02 measures as well. Learn more about Medisolv’s Hospital Quality Reporting Package, which includes all of these measures as eCQMs and includes the ability to stratify performance by race, gender, ethnicity, and payer.

If your hospital or CAH offers emergency services

4. Protocols: Hospitals must have adequate protocols to meet the emergency needs of patients, tailored to the complexity and scope of services they offer. Protocols must align with nationally recognized, evidence-based guidelines for emergency patient care. Hospitals are required to articulate these standards and identify the sources of these guidelines. For example, facilities may utilize a national medical professional society, accrediting organization, credentialling body, or other national guidelines.

5. Training: It is mandatory for applicable emergency services personnel to be trained annually on these protocols and provisions. Under the final rule, this mandate applies to acute care hospitals only; CAHs are exempt.

6. Provisions: Hospitals are required to keep stocked certain provisions, including equipment, supplies, and medication used in treating emergency cases. Hospitals can determine the appropriate type and quantity of these provisions. The available provisions must include:

• Drugs, blood and blood products, and biologicals commonly used in life-saving procedures
• Equipment and supplies commonly used in life-saving procedures
• A call-in-system for each patient in each emergency services treatment area

For all hospitals and CAHs

7. Document Transfer Protocols: Hospitals must have written policies and procedures for transferring patients, including transfers from the emergency department to inpatient admission, between inpatient units, and between different hospitals.

8. Protocol Training: It is mandatory that relevant staff be trained on these protocols.

Get Help Navigating Your 2025 OPPS Requirements

If you’re feeling overwhelmed by all the changes coming down the pike, you’re not alone. Our Hospital Quality Reporting Package, combined with our dedicated Clinical Quality Advisors, helps you make sense of all the noise and transform your data into meaningful performance results and patient care improvements. Schedule a 1:1 call today to learn more.

For more information on the 2025 OPPS Final Ruling, be sure to check out CMS’s online resources:

• OPPS Final Rule
• 2025 OPPS Final Rule Fact Sheet