FIMC®-Surgery

On Nov 21, CMS finalized the 2026 Hospital Outpatient Prospective Payment System OPPS and Ambulatory Surgical Center ASC rule

• The rule focuses on

  • Expanding outpatient care

  • Reducing inpatient only services

  • Improving hospital price transparency

  • Strengthening safety and accountability

• These changes increase workload and job demand for coders billers auditors and compliance teams

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Hospital Outpatient and ASC Changes

• CMS is phasing out the inpatient only list over three years

• In 2026

  • 285 procedures removed from the inpatient only list

  • 289 procedures added to the ASC covered list

  • Most procedures are musculoskeletal and surgical

• Medicare can still pay for these procedures in hospital outpatient departments when clinically appropriate

Impact

• More surgeries will shift to outpatient and ASC settings

• Higher demand for OPPS APC coding skills

• Increased focus on medical necessity documentation

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• CMS continues the two midnight policy review exemption for procedures removed from the inpatient only list

• This remains in place until CMS confirms the procedures are more common in ASCs

Impact

• Reduced immediate audit pressure

• Documentation accuracy remains critical

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• Outpatient payment rates will increase by 2.6 percent in 2026 for hospitals meeting quality reporting requirements

Impact

• Strong link between quality reporting and revenue

• Clean claims and correct coding become more important

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• ASC payment rates will continue to use the hospital market basket update

• CMS will continue monitoring outpatient procedure migration

Impact

• Growth in ASC coding and billing roles

• Increased demand for surgery and anesthesia coding expertise

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• CMS will align payments for certain outpatient services across hospital outpatient departments and off campus facilities

• This supports site neutral payments

Impact

• More payer edits related to place of service

• Higher risk of denials if site selection is incorrect

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• CMS will continue the two tier payment system for intensive outpatient program services

• One payment tier for three services per day

• Higher tier for four or more services per day

Impact

• Accurate service counting and documentation required

• Increased outpatient behavioral health billing activity

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• CMS estimates the rule will save Medicare and beneficiaries billions by reducing unnecessary services

Impact

• Increased audits

• Greater focus on payment integrity and compliance

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Hospital Price Transparency Updates

• Hospitals must now publish actual consumer friendly prices, not estimates

• Noncompliance can result in civil monetary penalties

Impact

• More internal audits of charge data

• Coding and billing accuracy directly affect compliance

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• From Jan 1 2026, hospitals must include in machine readable files

  • Median allowed amount

  • 10th percentile allowed amount

  • 90th percentile allowed amount

• Enforcement of some requirements delayed to Apr 1 2026

Impact

• Increased data validation work

• Billing and finance teams must align remittance data

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• Hospitals must attest that pricing data is accurate complete and current

• All payer specific negotiated charges must be included

Impact

• Higher accountability for errors

• Coding billing and contract mismatches can create risk

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• Hospitals must list the name of a senior executive responsible for pricing data accuracy

Impact

• Greater leadership oversight

• Less tolerance for billing and coding errors

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• CMS requires hospitals to include Type 2 NPIs in pricing files

Impact

• Accurate facility identifiers become critical

• Errors affect reporting and comparisons

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• Hospitals that accept CMS noncompliance findings may receive reduced penalties, except in serious violations

Impact

• Compliance prevention becomes a priority

• More routine internal checks

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CMS Hospital Star Ratings Change

• From 2026

  • Hospitals in the lowest safety quartile cannot receive a 5 star rating

• In future years

  • Poor safety performance may lead to automatic rating downgrades

Impact

• Quality and safety documentation gain importance

• Accurate coding supports valid quality reporting

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What This Means for Careers

• Outpatient coding jobs will grow faster than inpatient roles

• ASC coding billing and QA demand will increase

• Denials appeals and AR workloads will rise

• Audit and compliance roles will expand

• India based RCM teams benefit from increased outsourcing

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• CMS 2026 OPPS and ASC rule means

  • More outpatient volume – More demand for Medical Coders

  • More compliance work, 

  • Demand more for Surgery Coders

  • More audits and documentation review

  • More jobs for skilled medical coders and billers

For students and professionals, outpatient expertise compliance knowledge and certification are the keys to success in 2026 and beyond.