The Centers for Medicare & Medicaid Services (CMS) has released the final Calendar Year 2026 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rule, shaping reimbursement for nearly 4,000 hospitals and 6,000 surgery centers nationwide.
For CY 2026, hospitals and ASCs that meet quality-reporting standards will receive a 2.6% payment increase. While positive, the update falls below inflation, signaling a year where outpatient volumes will grow but margins remain tight.
A major structural shift in the rule is CMS’ continued effort to expand care delivery beyond inpatient settings. The agency is removing 285 musculoskeletal procedures from the Inpatient Only (IPO) list as part of a three-year phase-out. This change will allow more orthopedic, spine, and specialty cases to occur in hospital outpatient departments and, for many procedures, ASCs.
CMS also expanded the ASC Covered Procedures List (CPL), adding 271 codes newly eligible for ASC reimbursement in 2026. As more specialty procedures migrate outpatient, provider organizations face increasing operational pressure to ensure accurate coding, correct site-of-service billing, and clean claim submission.
CMS further advanced cost-control measures, including reducing reimbursement for certain drug-administration services furnished in off-campus provider-based departments. This policy alone is projected to save Medicare $220 million and beneficiaries $70 million in 2026, shifting even more financial responsibility onto hospitals and physician groups.
Quality and transparency are central themes of the rule. Beginning in 2026, CMS will require hospitals to encode median, 10th, and 90th-percentile allowed amounts in machine-readable price transparency files. The Hospital Overall Star Rating methodology will also place greater weight on patient-safety metrics, influencing financial performance and public perception.
What This Means for Providers
CY 2026 accelerates a clear trend: more specialty care delivered outpatient, higher compliance expectations, and lower margins. Hospitals and practices must manage rising case volumes alongside increasing administrative complexity, particularly in orthopedics, cardiovascular, and gastroenterology.
Cosentus supports providers through this transition with stronger pre-service revenue-cycle workflows, accurate coding and charge capture, denial prevention, and payer-quality analytics. As reimbursement models tighten, these capabilities help organizations protect revenue and maintain financial stability in an increasingly outpatient landscape.
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