CMS July 2025 OPPS Update: Key Changes Providers Need to Know

The Centers for Medicare & Medicaid Services (CMS) had released its July 2025 quarterly update to the Outpatient Prospective Payment System (OPPS), introducing coding and billing changes that took effect on July 1, 2025. This update—reflected in the Integrated Outpatient Code Editor (I/OCE)—carries important implications for hospital outpatient departments, revenue integrity teams, and billing professionals.

From status indicator (SI) adjustments to new vaccine codes and skin substitute product classifications, the changes highlight CMS’s ongoing efforts to align payment policy with clinical and regulatory developments.

1. New Vaccine CPT® Codes and COVID-19 Therapy Changes

The American Medical Association (AMA) has released six new Current Procedural Terminology (CPT®) codes linked to COVID-19, influenza, and respiratory syncytial virus (RSV) vaccines:

• 90382, 90612, 90613, 90635, 91323, 90631

These codes are available for use pending FDA approval and have been assigned SI “E1” (items not paid under OPPS).

Additionally, effective December 31, 2024, CMS deleted HCPCS code M0248 (COVID-19 monoclonal antibody therapy administration) following the FDA’s revocation of its Emergency Use Authorization (EUA).

2. Drug, Biological, and Radiopharmaceutical Code Updates

The July 2025 OPPS update includes extensive revisions to codes for drugs, biologicals, and radiopharmaceuticals, impacting payment and compliance tracking:

• 34 new HCPCS codes established; 8 codes deleted
• Several pass-through status changes
• SI changes for Q5136 and Q9998 from “E2” (items not covered by OPPS) to “K” (non-pass-through drugs and biologicals paid separately under OPPS)

Retroactive payment changes:

• HCPCS codes J9038, Q5151, Q5152 now have SI “K,” effective April 1, 2025

3. Correction of Duplicate Drug Codes

A coding duplication error from the April 2025 OPPS update has been resolved:

• Between April 1 and June 30, 2025, two active HCPCS codes existed for the same drug: C9173 (now deleted) and Q5148
• SI assignments during this period: C9173 → E1, Q5148 → G (pass-through drugs and biologicals)

4. Skin Substitute Product Reclassifications

CMS has made significant updates to skin substitute products:

• 13 new HCPCS codes (Q4368–Q4380, Q4382) created and assigned SI “N” (items packaged into the payment for the associated procedure) due to insufficient pricing data
• HCPCS Q4309 reassigned from the low-cost to the high-cost skin substitute group

These changes directly affect reimbursement rates for wound care and reconstructive procedures, making it essential for coders to use the updated product lists.

5. Additional Updates: PLA Codes, CPT® Category III Codes, and Devices

Beyond drugs and biologics, CMS has also updated:

• Proprietary Laboratory Analyses (PLA) codes – to capture novel diagnostic tests entering the market
• CPT® Category III codes – reflecting emerging technologies and procedures
• Device categories – aligning payment classification with new product approvals

Why This Matters for Providers and Revenue Integrity Teams

The July 2025 OPPS update isn’t just a list of code changes—it represents real financial and compliance impacts:

• Accurate reimbursement: Incorrect SI usage can lead to payment denials or underpayments.
• Regulatory compliance: Misalignment with current code sets increases audit risk.
• Operational readiness: Pharmacy, laboratory, and surgical teams must coordinate to ensure products are billed correctly from day one.

Billing and coding leaders should review these changes in detail, update charge description masters (CDMs), and communicate updates to clinical and financial stakeholders.

Final Takeaway

CMS’s quarterly OPPS updates are dense, but each change carries weight in terms of payment accuracy, compliance, and operational flow. The July 2025 update—with its mix of new codes, deletions, SI changes, and reclassifications—demands a proactive review process to safeguard revenue and avoid costly rework.

Outsourcing OPPS and HCPCS update management to a professional revenue cycle partner can help ensure these changes are implemented quickly, accurately, and in full compliance—freeing your internal teams to focus on patient care.

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