CMS Releases CY 2026 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Proposed Rule

On July 15, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2026 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule, outlining updates to Medicare payment policies and rates for hospital outpatient services. Comments are due September 15, 2025.

Key Takeaways for Audiology Include:

Updates to OPPS and ASC payment rates

For CY 2026, CMS proposes a 2.4 percent payment increase for both hospital OPPS and ASC rates, contingent on meeting quality reporting requirements. This reflects a 3.2 percent market basket increase, reduced by a 0.8 percent productivity adjustment, consistent with the IPPS update factor.

APC Placement

The audiology codes maintained their current Ambulatory Payment Classification (APC) placement in the CY 2026 OPPS proposed rule; however, the payment rates associated with those APCs varied, with some increasing and others decreasing. While the preservation of APC placement ensures continued alignment within established service groupings, the reductions for certain APCs may negatively impact reimbursement levels and the financial sustainability of those audiology services in hospital outpatient settings.

Staff will continue to review and investigate the underlying rationale for these rate changes, including any shifts in claims data, cost report inputs, or broader policy adjustments that may have influenced the proposed valuations.

Defer to Others on Quality Issues

Software as a Service (SaaS)

The use of software-based technologies to support clinical decision-making in outpatient and physician office settings has grown rapidly. Medicare refers to these tools as Software as a Service (SaaS). However, CMS currently lacks a comprehensive payment policy that reflects the unique characteristics of these services.

For CY 2026, CMS is soliciting public comment on how to structure payment for SaaS under the OPPS. The agency is particularly interested in insights from risk-bearing payment models and input on how to incorporate the clinical value of technology into payment policy. CMS is also requesting similar feedback under the CY 2026 Physician Fee Schedule (PFS) proposed rule.

Resources:

CY2026 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Ratings; and Hospital Price Transparency 

CY2026 HOPD/ASC FAQ Sheet