Outpatient new technology payments
By the end of 2024, Medicare expenditures on outpatient care across eligible hospitals reached $62 billion (about $190 per person in the US)—a reflection of shifts in care delivery models, technological advancements, and the increasing trend of physician employment by hospitals. Spending on outpatient hospital services grew at an annual rate of 6.9% between 2012 and 2022.
What drives Medicare’s outpatient payment system?
Medicare’s Outpatient Prospective Payment System (OPPS), introduced in 2000, structures payments to hospital outpatient departments based on predefined groupings of services, known as Ambulatory Payment Classifications (APCs).
Services in each APC share clinical and cost similarities, with a single payment rate applied across the board. Medicare provides composite payments for bundled services, such as multiple imaging tests conducted during a single visit. Meanwhile, some items, like blood products and high-cost drugs, are reimbursed separately to ensure equitable compensation. For newer technologies and procedures, CMS utilizes “New Technology APCs” to ensure coverage until sufficient data is available to assign these services to standard APCs.
CPT® (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes play a crucial role in this system, as they serve as the foundation for categorizing services and linking them to their respective APCs. For New Technology APCs, CPT codes enable accurate identification and reporting of innovative procedures or technologies, allowing CMS to assign appropriate payment rates.
Encouraging innovation
New Technology APCs are an exception to the standard CMS method for setting payment rates. CMS uses “New Technology” APCs for services that lack sufficient cost data for standard APCs. These services remain in New Technology APCs for two to three years until enough data is available for accurate payment rates.
New Technology APCs are assigned cost ranges (e.g., $0-$10 to $145,000-$160,000), and CMS sets payment rates at the midpoint of the range. Unlike standard APCs, payments for New Technology APCs are exempt from budget-neutrality adjustments, increasing total OPPS spending.
The procedures or technologies within these cost bands can be documented with the CPT/HCPCS codes as indicated in the published final rule. CPT and HCPCS codes are essential for categorizing services and linking them to APCs. For New Technology APCs, CPT codes help identify and report innovative procedures, enabling CMS to assign correct payment rates.
New Technology APCs – CMS Final Rule CY 2025
| Technology | CPT/HCPCS Codes |
|---|---|
| Administration of Subretinal Therapies Requiring Vitrectomy | HCPCS 0810T |
| Biology Guided Radiation Therapy (BgRT) | HCPCS G0562, G0563 |
| Blinded Interatrial Shunt Procedure | HCPCS C9758 |
| Bronchoscopy With Transbronchial Ablation of Lesion(s) by Microwave Energy | HCPCS C9751 |
| Cardiac Positron Emission Tomography (PET)/Computed Tomography (CT) Studies | CPT 7843, 78432, 78433 |
| CardiAMP | HCPCS C9782 |
| Atherosclerosis Imaging-Quantitative Computer Tomography (AI-QCT) | CPT 0625T |
| Corvia Medical Interatrial Shunt Procedure | HCPCS C9760 |
| DARI Motion Procedure | CPT 0693T |
| Instillation of Anti-Neoplastic Pharmacologic/Biologic Agent Into Renal Pelvis | HCPCS C9789 |
| LimFlow TADV Procedure CPT Code | CPT 0620T |
| Liver Histotripsy Service | CPT 0686T |
| LiverMultiScan Service | CPT 0648T, 0649T |
| Optellum Lung Cancer Prediction (LCP) | CPT 0721T, 0722T |
| Quantitative Magnetic Resonance (QMR) for Analysis of Tissue Composition | CPT 0648T, 0649T |
| Quantitative Magnetic Resonance Cholangiopancreatography (QMRCP) | CPT 0723T, 0724T |
| Scalp Cooling | HCPCS 0662T |
| Supervised Visits for Esketamine Self-Administration | HCPCS 02082, 02083 |
| Surfacer® Inside-Out® Access Catheter System | HCPCS C9780 |
| Transcatheter Atrial Shunt System (TASS) | HCPCS C9792 |
| Magnetic Resonance Imaging with Inhaled Hyperpolarized Xenon-129 Contrast Agent | CPT C9791 |
| SAINT Neuromodulation System | CPT 0889T, 0890T, 0891T, 0892T |
Looking ahead
The OPPS incentivizes hospitals to evaluate their treatment methods carefully. Packaging services into comprehensive APCs encourages cost-effective care by bundling related services into a single payment. APCs rely on CPT and HCPCS codes, making it crucial to stay informed about new technology codes and payment updates.
Medicare’s outpatient payment system continues to evolve, adapting to advancements in technology and shifting care paradigms. Awareness of new technology payment eligibility will be essential for providers, beneficiaries, and other stakeholders within the healthcare ecosystem.
Click here to learn more about CPT codes, including key updates for 2025, and here to read our HCPCS 101 guide.
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