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  • November 26 ,2025

Breaking Down the CY 2026 OPPS/ASC Final Rule: What Revenue Cycle Leaders Must Know

The CY 2026 OPPS and ASC Final Rule brings major changes to the outpatient landscape — from expanded ASC procedural eligibility and site-neutral payment reforms to price transparency and reporting shifts. This article breaks down the final rule in clear terms, explains what it means for operational and financial performance, and outlines how ASCs and outpatient providers can prepare now to protect revenue and accelerate growth in 2026.

 

Key Takeaways

  • CMS finalized a 2.6% payment update for both ASCs and HOPDs, continuing ASC alignment with the hospital market basket.
  • Hundreds of new musculoskeletal, cardiovascular, spine, and vascular procedures are being added to the ASC Covered Procedures List as CMS phases out the inpatient-only list.
  • New site-neutral payment policies aim to reduce patient copay differences between HOPDs and off-campus facilities.
  • CMS is pausing several quality measures, easing administrative burden for ASCs while continuing to refine safety-focused reporting requirements.
  • Reimbursement corrections, including for cardiac procedures, prevent steep proposed cuts and instead result in positive payment adjustments.

Bottom line: This Final Rule creates new reimbursement opportunities for ASCs — but only for organizations prepared to adapt billing strategies, optimize documentation, and modernize patient financial engagement.

 

The CY 2026 “Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System” Final Rule — released by CMS on November 21, 2025 — marks a pivotal moment for outpatient surgery, site-of-service strategy, and revenue-cycle planning.

For practices, ASCs, hospital outpatient departments (HOPDs) and billing partners alike, this rule signals both opportunity and change. From payment updates to list eliminations, site-neutral policies to transparency mandates, the landscape is shifting. Below we unpack the major themes, what they mean in practice, and how billing/revenue-cycle teams should prepare.

Payment Updates: A Modest Bump, but with Strategic Implications

One of the first takeaways: CMS finalized a 2.6% payment increase for ASC payment rates under the rule, reflecting a 3.3% hospital market basket update less a 0.7 percentage point productivity adjustment. HOPDs also see a 2.6% update for outpatient services meeting quality reporting requirements.

What this means for practices & billing partners:

  • While a 2.6% increase is modest, it is positive in a fiscal climate where cost pressures are mounting.
  • Billing teams should model the impact of this update across high-volume procedures, and consider how slight changes in conversion factors or cost structures may shift profitability.
  • For ASCs especially, the update signals CMS’s continued willingness to treat them as a growth site for outpatient procedures — so billing strategies, eligibility checks, documentation workflows and payer negotiation strategies should align.

Expanding the Covered Procedure List & Phasing Out the Inpatient-Only List

Perhaps the most consequential change: CMS is phasing out the “Inpatient-Only” (IPO) list over three years, beginning in CY 2026 with ~285 primarily musculoskeletal procedures removed. Meanwhile, the ASC Covered Procedures List (CPL) was expanded by eliminating five general exclusion criteria (now recast as “non-binding physician considerations for patient safety”) and adding hundreds of codes — including 276 procedures already paid in HOPDs plus 271 codes removed from the IPO list.

Why this matters:

  • For ASCs: this is a major growth vector — more procedures can move to the ASC setting, meaning higher potential volume and revenue opportunity for the surgery-center side of the business.
  • For HOPDs: this may trigger re-evaluation of site-of-service migration risk (i.e., procedures formerly performed in the hospital outpatient department may migrate to the ASC). Billing/risk-management teams should monitor procedure mix, payer contracts and site-of-service decisions.
  • For both parties: documentation, coding and patient suitability processes become even more critical. With more codes eligible in the ASC setting, mis-siteing — or missing an ASC opportunity — can result in lost revenue or increased denials.

Site-Neutral Payment Policies & Location-Based Copay Alignment

The rule also advances CMS’s site-neutral payment agenda. For CY 2026, CMS finalised a policy to align payment rates for select outpatient services furnished in hospital outpatient departments and off-campus facilities in order to avoid higher beneficiary copays based on the location of care. For example: drug-administration codes furnished in grandfathered off-campus provider-based departments (PBDs) will be paid at the Physician Fee Schedule (PFS) equivalent rate rather than the full OPPS rate.

Implications for revenue cycle and billing strategy:

  • This change can affect payer contract negotiations and internal budgeting, since the payment variance between site settings is narrowing.
  • Practices and hospital groups should review their site-of-service decision frameworks: is a procedure best performed in a hospital outpatient department, an independent ASC or a physician office? The “cost to the patient” (copay and coinsurance) and reimbursement potential will shift.
  • Patient-financial-experience teams must ensure clear communication to patients about cost differences by site and the rationale for choosing a given site (both for patient satisfaction and compliance/fair-billing).

Quality Reporting & Transparency: Evolving Expectations

CMS continues to refine its quality-reporting and transparency obligations — for hospitals, ASCs and HOPDs alike.

  • On the ASC side, the rule pauses certain proposed metrics (such as “Patient Understanding of Key Information Related to Recovery After Facility-based Outpatient Procedure or Surgery” and “Patient Reported Outcome-Based Performance Measures”) and declines to require ASCs to use the Hospital Quality Reporting system for ASC data in CY 2026.
  • On pricing transparency, CMS tightens requirements for hospitals: replacing “estimated allowed amount” with “median allowed amount” plus the 10th/90th percentile allowed amounts; hospitals must attest that the information is accurate and complete in their machine-readable files (MRFs).

Action steps for billing/revenue-cycle teams and practice leadership:

  • Ensure your ASC or practice-billing vendor is ready for these evolving metrics — even if new metrics are delayed, you’ll need systems in place to collect, validate and report.
  • Engage your patient-financial-experience team: transparency obligations mean patients may more proactively compare costs across providers/sites. Billing teams should ensure patient estimates, disclosure of charges/allowed amounts and self-pay workflows are robust.
  • Review contract terms and Payer mix: as site-neutral and transparency policies accelerate, payers may intensify cost containment pressures, requiring tighter cost-management and efficient billing practices.

Special-Purpose Provisions: Non-Opioid Pain Treatments, Radiopharmaceutical Incentives & More

Beyond the headline items, the rule includes important “special-purpose” elements that revenue-cycle teams should monitor:

  • CMS finalized separate payments in CY 2026 for certain non-opioid treatments for pain in both HOPD and ASC settings (five drugs, eleven devices) — part of the broader effort to reduce opioid reliance.
  • A new add-on payment of $10 per dose for technetium-99m radiopharmaceuticals (Tc-99m) derived from domestically produced molybdenum-99 (Mo-99) was codified (HCPCS C9176) for services starting January 1, 2026. 

Why these matter:

  • These are niche but growing areas of outpatient care; practices and ASCs engaged in imaging, interventional radiology or pain-management should evaluate whether their workflows/coding are optimized to capture these payments.
  • Billing/coding teams must ensure capture of correct HCPCS codes, modifiers, documentation of non-opioid treatment qualification and any ancillary costs to support billing these services.

What Should Practices & ASCs Do Now: A 90-Day Action Plan

To convert this rule from “its implication” to “an actionable plan,” here’s a rough 90-day checklist for practices, ASCs and billing partners:

  1. Update your policy-and-procedure manuals & internal workflows — including site-of-service decision trees (i.e., hospital vs ASC), update of codes newly added to ASC-CPL, and internal price-transparency/estimate processes.
  2. Run a reimbursement impact model — using your top 20-30 outpatient procedures, project what the new rules mean for reimbursement, payer mix shifts and patient cost-sharing.
  3. Engage coding/billing team for training — highlight the codes added to ASC eligibility, ensure consistent use of HCPCS/Modifiers for non-opioid treatments and radiopharmaceuticals, and refresh documentation expectations for the new site-neutral business rules.
  4. Review payer contracts & site-of-service clauses — particularly for out-patient services performed at off-campus provider-based departments or ASCs. Negotiate or renegotiate where possible to ensure favorable reimbursement and clarity for patient cost-sharing.
  5. Check your patient-financial-experience workflows — ensure your estimates, self-service tools, disclosure statements, and AR follow-up processes are aligned for the transparency environment.
  6. Partner with your RCM/billing outsourcing vendor (or consider one) — ensure they are aware, ready and equipped for the 2026 changes; define joint monitoring of denials, site migration, key code-monitoring and payer behavior changes.

In Conclusion: A Forward-Looking Lens on Revenue Cycle Trends

The CY 2026 OPPS/ASC Final Rule is more than a routine payment update — it represents a strategic shift in how outpatient surgery and site-of-service decisions will be treated by Medicare. With payment updates, expanded ASC eligibility, site-neutral policies and increased transparency, the revenue-cycle environment is evolving.

For practices, ASCs and billing partners, the key is to anticipate, align workflow & documentation, and position for advantage in this new environment. Those who treat this not simply as “another final rule” but as a driver of strategic change — for coding, site strategy, documentation, patient experience and payer negotiation — will be best placed.

Maximize ASC Revenue in 2026 with a Smarter, Compliance-Driven Billing Strategy

Navigating the evolving OPPS and ASC payment landscape isn’t just a regulatory requirement — it’s a financial strategy. With new procedures shifting to ASC eligibility, tightening price-transparency rules, and greater pressure toward site neutrality, practices must ensure their revenue cycle is optimized from pre-authorization to final reimbursement.

That’s where Bristol Healthcare Services delivers measurable value.

Our ASC Revenue Cycle Expertise Includes:

Whether you’re an independent ASC or part of a hospital-affiliated network, we help you capture every dollar you earn — accurately, compliantly, and efficiently.

Let’s build a stronger outpatient future together.

Contact Bristol Healthcare Services today to strengthen your ASC revenue cycle and maximize reimbursements under CY 2026 payment policies.

Click the link to learn more about our Ambulatory Surgical Center billing services, and revenue cycle management solutions.