CMS Releases CY 2026 HOPPS/ASC Final Rule

The Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2026 Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center (ASC) Payment System final rule on November 21. Policies outlined in the rule will take effect January 1, 2026. The following AAO-HNS overview provides details regarding the rule’s key provisions impacting the field of otolaryngology.

For more information, view the CMS Fact Sheet and Press Release. For questions regarding provisions impacting otolaryngology-head and neck surgery, contact the AAO-HNS Health Policy Advocacy team: [email protected].

HOPPS/ASC Payment Rate Updates

The HOPPS/ASC final rule focuses on Medicare payment for procedures and services furnished in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). For CY 2026, CMS is continuing its policy of updating ASC and HOPD payment rates using the hospital market basket, which reflects estimated changes in the cost for hospitals to deliver care (including wages, supplies, equipment, etc.). CMS initially adopted the use of the hospital market basket update to determine HOPD and ASC payment for a five-year period (2019-2023), but CMS will continue to extend this policy through at least 2026.

For CY 2026, the HOPPS/ASC payment rate is increasing by 2.6%, reflecting the hospital market update (+3.3%) and a productivity adjustment (–0.7%) required by federal law. This update factor applies only to the facility payment component in HOPD and ASC settings.

Device-Intensive Procedure Determinations:

In an effort to better capture the high device costs associated with some procedures, the HOPPS/ASC final rule also determines which Medicare services are designated as “device-intensive.” Device-intensive status increases the portion of the payment rate intended to cover device costs, so changes to these classifications can meaningfully influence facility reimbursement. For CY 2026,

• CPT 31295 (nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa) is designated as device intensive.
• CPT 31296 (nasal/sinus endoscopy, frontal sinus ostium) is designated as not device intensive.

Updated APC Assignments for Hypoglossal Nerve Stimulation

CMS uses APCs, or Ambulatory Payment Classifications, to pay for all items and services in the hospital outpatient department paid for under the OPPS. Procedures that are similar in nature and require similar resources are grouped into the same APC and assigned a payment rate in the outpatient setting based on the average cost of the services in the group. For CY 2026, CMS has opted to update the assigned APCs, or Ambulatory Payment Classifications, for two codes related to hypoglossal nerve stimulation.

• CMS finalized the placement of CPT 64568 (open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator) in APC 1580: New Technology Level 43 ($40,001-$50,000).
• CMS finalized the placement of CPT 0786T (insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed) in APC 5463: Level 3 Neurostimulator and Related Procedures ($11,384.04).
• CPT 64582 (open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array) will remain in APC 5465: Level 5 Neurostimulator and Related Procedures ($31,526.06) for CY 2026.

Additional APCs of relevance to otolaryngology-head and neck surgery are listed in the table below. To verify the APC placement for a specific code, reference the 2026 OPPS Addendum B or contact the AAO-HNS Health Policy Advocacy team: [email protected].