Ambulatory Surgical Centers (ASCs) are facing significant updates, particularly in Medicare reimbursement policies, quality reporting, and evolving administrative requirements. While changes bring positive adjustments for ASCs, challenges related to reimbursement cuts, regulatory burdens, and changes in drug pass-through status present trials. Below is an overview of the key developments that will impact ASCs in 2025.

CMS finalizes 2.9% payment rate increase for 2025

The Centers for Medicare & Medicaid Services (CMS) has finalized a 2.9% reimbursement increase for ASCs that meet the necessary quality reporting requirements. This adjustment is based on a projected 3.4% increase in the hospital market basket, reduced by a 0.5% productivity adjustment. The finalized ASC conversion factor for 2025 is set at $54.895, an increase from the previous year, which reflects CMS’s acknowledgment of rising costs in the outpatient setting.¹

However, this increase is insufficient, as it does not fully offset health-care cost inflation. Although the payment increase provides some relief, ASCs will continue to face financial challenges due to fiscal pressures within the Medicare system.

Cataract surgery reimbursement increase

Specific examples of the payment increase are the average +3.8% increase for blepharoplasty surgeries and +2.6% ASC reimbursement boost for cataract surgery in 2025.² Although this increase is a step forward, the reimbursement is still behind the rising inflation of medical costs. Since these reimbursements are tied to hospital outpatient rates, rather than actual inflation or cost of care, ASCs often find it necessary to supplement their income with non-Medicare services. 

Ophthalmic practices, for example, are leveraging premium cash-pay services such as premium lenses to offset Medicare shortfalls; however, there are coding pitfalls that ASCs need to be aware of. For a review of how to code for premium lenses in cataract surgery, see my article, “Proper Medicare Coding for Premium Lenses in Cataract Surgery” in the February 2023 issue of The Ophthalmic ASC. ASCs that rely solely on Medicare reimbursement may struggle to keep up with the financial demands of providing high-quality care.

Nonopioid pain management drug policy

ASCs will also need to navigate changes to the reimbursement structure for nonopioid pain management drugs. Omidria (phenylephrine andketorolac, Rayner) and Dextenza (dexamethasone lacrimal ophthalmic insert, Ocular Therapeutix) will continue to receive separate payment for the procedures in which they are used. However, CMS has finalized a policy that caps reimbursements for these drugs at specific amounts—$427.57 for Dextenza and $425.89 for Omidria per date of service.^1,3

While these drugs are designed to reduce opioid use, their higher reimbursement costs can become a significant burden when limited by the new caps. For ASCs, this change necessitates careful management of resource allocation to avoid financial shortfalls related to these pain management solutions.

Changes in pass-through drug status

Although not commonly used in the ASC setting, 2025 involves the expiration of pass-through status for certain ophthalmic drugs. Drugs like Xipere (triamcinolone acetonide, Bausch + Lomb) and Susvimo (ranibizumab, Genentech) will lose their pass-through status by March 31, 2025, which means they will no longer be reimbursed separately from the facility fee.³

Pass-through drugs are typically reimbursed at a higher rate to ensure that ASCs can afford them. Once pass-through status expires, however, these drugs may still be separately payable, but only if they meet specific criteria for reimbursement.

New iris prosthesis code

Effective January 1, 2025, Category I CPT code 66683 will be available for the “implantation of iris prosthesis, including suture fixation and repair or removal of the iris, when performed.” This new permanent code replaces the temporary Category III CPT codes 0616T, 0617T, and 0618T. Additionally, the existing iris prosthesis procedure family has been revalued and future National Correct Coding Initiative (NCCI) or bundling edits will be applied to associated codes.⁴

ASC Quality Reporting (ASCQR) Program changes

Another notable development for ASCs in 2025 is the continuation of the voluntary status of ASC-11 (Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery) for the reporting year. Despite strong opposition from ophthalmic organizations, CMS has also decided to proceed with the introduction of three health equity measures under the ASCQR program.³

The new measures focus on:

• Facility commitment to health equity with voluntary reporting for 2025, mandatory from 2027.
• Screening for social drivers of health with voluntary reporting for 2025, mandatory from 2026.
• Screen positive rate for social drivers of health with voluntary reporting for 2025, mandatory from 2026.

These measures are part of CMS’s push to promote health equity, but they present additional reporting and operational burdens. Furthermore, these measures have never been tested in the ASC setting. ASCs will need to develop systems to track and report on social determinants of health, which may require significant administrative investment.

Ongoing administrative burdens

ASCs are facing increasing administrative burdens due to prior authorization and step therapy requirements imposed by private insurers and Medicare Advantage plans. These restrictions often delay or deny patients access to essential procedures, particularly in ophthalmology, where such delays can impact outcomes for conditions like cataracts and glaucoma.

Additionally, CMS is considering expanding the HOPD prior authorization requirements to ASCs, specifically for procedures such as blepharoplasty and botulinum toxin injections. While the rollout of this pilot program has been delayed until later in 2025, ASCs must be prepared for future changes in prior authorization policies, which could further increase administrative challenges and costs.³

Conclusion

The year 2025 will present opportunities and challenges for ophthalmic ASCs. While Medicare and CMS have provided increases in reimbursement rates, particularly for cataract surgery, ongoing changes to drug payment policies add complexity.

The shift toward health equity reporting and the potential expansion of prior authorization to ASCs will require centers to adapt to evolving regulations. To successfully manage these changes, ASCs will need to balance operational efficiency with strategic revenue management and appropriately maximize reimbursement by leveraging both Medicare and private pay options. OASC

References
1. CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC) | CMS. https://tinyurl.com/5477urtn. Accessed Dec. 6, 2024.
2. Final 2025 ASC Payment Regulation: Facility Fees to Increase by 2.9 Percent - OOSS. https://tinyurl.com/59v5jbck. Accessed Dec. 10, 2024.
3. CMS Finalizes 2.9% Pay Increase for Hospital Outpatient, ASC Settings for 2025 - American Academy of Ophthalmology. https://tinyurl.com/yc7bdjay. Accessed Dec. 6, 2024.
4. 2025 Coding Update - American Academy of Ophthalmology. https://www.aao.org/eyenet/academy-live/detail/2025-coding-update. Accessed Dec. 6, 2024.

Brandy Keys, MPH, is the director of health policy at the American Academy of Ophthalmology, where she leads efforts on federal policy related to coverage, reimbursement, quality measurement, and Medicare for ophthalmologists. She has a background in revenue cycle management and consulting for independent physician practices.

Matthew Baugh, MHA, COT, OCS, OCSR, is a coding and reimbursement manager for the American Academy of Ophthalmology in San Francisco. Reach him at mbaugh@aao.org.