By Michael A. Romansky, JD

Late fall of 2025 provided the ophthalmic ASC community with several substantial—and not necessarily expected—victories in Washington. After threatening to significantly reduce cataract facility fees in the proposed 2026 ASC payment rule, the US Centers for Medicare and Medicaid Services (CMS) ultimately granted a meaningful increase for CPT 66984 and related procedures. Facilities will no longer be required to report on several unnecessary and outdated ASC quality measures. Although the ophthalmology community has fought implementation of a Medicare prior authorization demonstration project impacting several eye procedures, mandatory participation by facilities has been delayed, and changes are being made that will ameliorate administrative burdens. CMS continues to pay for cataract surgery in the ASC and not in the office-based surgical suite. 

We make progress in achieving our reimbursement, regulatory, and legislative objectives through the application of several guiding advocacy principles:

• The indefatigable commitment of our lay physician leadership;

• A full-time lobbying presence in the nation’s capital;
  
  
• Strong alliances among, and coordination by, colleague ophthalmology and ASC organizations in addressing our concerns before policymakers;

• Sound, data-driven policy recommendations;

• Active grassroots engagement by our members; and

• Political fundraising.

All of these principles came into play with respect to the 2026 payment regulation and other initiatives.

ASC Payment Rates in 2026

Under the final rule, overall ASC payment rates will be increased by 2.6%, reflecting the hospital market basket index of 3.3% less the MFP adjustment of 0.7%. The increase represents an average across all ASC procedures. CMS proposed that 2026 payments for cataract surgery (CPTs 66984 and 66170) be reduced by 4.7% from 2025 levels, the first decrease in memory. The Outpatient Ophthalmic Surgery Society (OOSS), joined by our colleague ophthalmology organizations, maintained that CMS made a significant calculation error in establishing the cataract rate and requested that the agency review its work and correct any errors. Many thanks to the American Academy of Ophthalmology for funding a private analysis that documented the agency’s mistake. As a result of this effort, the 2026 facility fee for cataract surgery will be $1,255, an increase of 8.4% above the proposed rule, and 3.3% over 2025 levels.

Annual Payment Update Factor

Six years ago, CMS agreed, for the period 2019 to 2023, to update ASC payment rates by the hospital market basket rather than the lower Consumer Price Index for All Urban Consumers. OOSS has been a leader in the effort to effectuate this change for more than 20 years, seeking to persuade both CMS and Congress of its merits. After all, we treat the same patients as hospitals and incur comparable costs in the delivery of fare. Under this interim policy, ASCs have received the same update as hospitals, subject to certain adjustments. The policy was supposed to come up for review in this 2026 rulemaking. However, because of data problems associated with the pandemic, the agency last year extended the application of the hospital market basket to ASCs for an additional 2 years, through 2025 and, in this year’s final rule, the trial has been extended through 2026. OOSS and the ophthalmology and ASC professional organizations will continue to strenuously recommend that CMS maintain permanently the application of the hospital market basket in computing the annual ASC payment update. We are guardedly optimistic that we will achieve this objective.

ASC Quality Reporting

We are pleased that CMS is removing several measures that were opposed by OOSS and the ophthalmology and ASC communities: (1) the COVID-19 Coverage Among HCP measure; (2) the Facility Commitment to Health Equity measure beginning with the CY 2025 reporting period/CY 2027 program determination; (3) the Screening for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and (4) the Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. We are also pleased that no further action has been taken by the agency to require facilities to report on improvements in patient visual function in the 90 days following surgery, a policy that we have objected to for almost a decade.

Medicare Prior Authorization Pilot Project for ASCs

For the past 2 years, CMS has promised to initiate a 5-year demonstration project that will require ASCs in a dozen states to receive prior authorization from Part B Medicare carriers for 5 services, including blepharoplasty, blepharoptosis repair, brow ptosis repair, and botulinum toxin injection. The agency had planned on initiating implementation on December 15, 2025. Failure to submit services for prior authorization will result in retrospective reviews of claims and potential penalties. After meetings with and submissions by AAO, OOSS, and organizations representing the oculoplastics community, CMS is delaying this initiative as follows:

• Providers in California, Florida, Tennessee, Pennsylvania, Maryland, Georgia, and New York can submit prior authorization requests beginning on January 5, 2026, for dates of service on or after January 19, 2026.
   

• Providers in Texas, Arizona, and Ohio can submit prior authorization requests beginning on February 2 for dates of service on or after February 16. We continue to have significant concerns about the administration of the prior authorization demonstration project and will continue to advocate before the agency and the Medicare contractors for changes in the program that will ameliorate the administrative burden on ASCs.

Final Thoughts

Despite our successes on the legislative and regulatory fronts, we face innumerable challenges ahead in 2026: ASC payments, prior authorization, reimbursement for MIGS and related procedures, and office cataract surgery, to name a few. I urge you to continue to support OOSS and to be active in our grassroots lobbying initiatives. In deciding whether to engage, please ask yourself these questions: In the absence of OOSS’s work over these past 4 decades, could surgeons still own and refer their patients to ASCs? Would our facility payments have increased by 350%, or would they have declined like professional fees? Would we be able to perform and be paid for virtually every ophthalmic procedure in the ASC? Would Medicare ASC facility regulations be more burdensome, threatening the very viability of ophthalmic surgical centers?