Where ASC payment actually stands in 2026 — and what's queued for 2027

Ambulatory surgery centers entered 2026 with the most consequential payment rule in years. The CY2026 OPPS/ASC final rule, finalized November 21 and effective January 1, set the ASC update at 2.6% — the 3.3% hospital market basket minus a 0.7-percentage-point productivity adjustment — and, more importantly, rewrote what ASCs are allowed to do. The mechanics are documented in CMS’s summary in the Federal Register and in McDermott+‘s breakdown of the rule.

The list got longer. A lot longer.

CMS revised its covered-procedures criteria, downgrading five general exclusions to nonbinding “physician considerations,” and added 289 procedures to the ASC covered list. On top of that, the agency began a three-year phase-out of the inpatient-only list, removing 285 mostly musculoskeletal codes for 2026 and adding 271 of them directly to the ASC list. That’s 560 new covered procedures in one rule.

CMS projects roughly $9.2 billion in total ASC payments for CY2026, per McDermott+‘s read of the rule’s estimates.

Which code families actually moved

The phase-out matters because of what came off the inpatient-only list, not just how many. CMS’s first-year removals are, in the agency’s own framing, predominantly musculoskeletal — Applied Policy notes the rule “begins on January 1, 2026, with the removal of 285 mostly musculoskeletal-related services.” The final rule accelerated the full phase-out to January 1, 2028 — a year ahead of the proposed timeline — though its codified text still carries the proposal’s 2029 date in one place, an inconsistency CMS has yet to reconcile. Among the high-value families that moved onto the ASC covered list for 2026 are lumbar fusion spinal codes, per VMG Health’s procedure-level summary.

The single most-watched addition sits outside orthopedics. CMS added cardiac catheter ablation to the ASC list effective January 1, 2026 — HeartRhythm Advocates reports CMS “added several cornerstone EP ablation codes, including 93650, 93653, 93654, 93656, and related add-on codes, to the ASC-Covered Procedures List.” For any center weighing a cardiology or electrophysiology line, that is the code family to model first.

The gap is the policy

The structural arithmetic hasn’t moved: MedPAC’s March 2026 report puts the ASC conversion factor at $56.32 against $90.97 under the OPPS, and states that “for most services, the ASC payment rates are 46 percent lower than the HOPD payment rates.” That gap is not an accident of the math — it is the lever. MedPAC names it directly: because ASC rates are lower for every service covered in both settings, “the cost to FFS beneficiaries (via cost sharing) and the Medicare program (as well as taxpayers) is lower,” which is exactly why volume keeps migrating from hospital outpatient departments to ASCs.

The migration is measurable. MedPAC reports the number of Medicare-certified ASCs rose 2.2% to 6,436 in 2024, and that Medicare payments to ASCs reached $7.5 billion that year — up 13.0% from 2023, with payments per fee-for-service beneficiary up 15.9%. The commission attributes part of the shift to surgeons being able to “perform more procedures in ASCs than in HOPDs in the same amount of time,” and documents a move “to higher-complexity services in ASCs” — total knee, hip, and shoulder arthroplasty, none ASC-covered in 2019, are now among the highest-revenue ASC services, and revenue for percutaneous laminotomy or laminectomy “increased by a factor of 13 over the 2019 level.”

Where the growth is fastest tells you where the steering is heading. Among single-specialty ASCs, MedPAC reports the cardiology count grew 6.3% and the orthopedic count 18.9% from 2023 to 2024; among multispecialty centers, those combining pain management and orthopedics “grew most (20.9 percent).” The commission’s standing recommendation isn’t a raise; it’s that Congress require ASCs to submit cost data, “without which” — its long-running position — adequate payment can’t be set.

Congress has the parity question in front of it. H.R. 8091, the Outpatient Surgery Access Act of 2026, introduced in March by Reps. Beth Van Duyne and John Larson, would align ASC annual updates with hospital outpatient departments starting in 2027 and eliminate ASC-specific budget-neutrality adjustments. It is ASCA-endorsed and bipartisan; it has not moved past introduction.

What to model for 2027

The CY2027 proposed rule has not been published; the annual cycle points to July (the CY2026 version arrived July 17, 2025). Two signals from the current rule are worth budgeting against now. First, CMS kept the 340B-related offset at 0.5% for 2026 but wrote that it anticipates “a larger reduction (such as 2 percent)” beginning in CY2027. Second, the agency’s drug acquisition cost survey is timed to inform CY2027 policymaking — a wildcard for any center with meaningful drug spend.

A modeled comparison (illustrative, not a forecast). To size what the parity fight is worth, model one representative service two ways, holding the procedure’s relative weight constant. Assumptions: a procedure with an ASC relative weight of 10.0; the verified 2026 conversion factors of $56.32 (ASC) and $90.97 (OPPS); and, for the current-methodology path, an illustrative CY2027 ASC update of 2.5% — chosen only to approximate the recent market-basket-minus-productivity range, not because CMS has published a figure. Under current methodology, that procedure’s ASC rate moves from about $563 to roughly $577. Under H.R. 8091’s parity logic — same procedure, paid off the OPPS conversion factor at the same weight — the rate would sit near $910 before any 2027 update. The modeled gap on this single illustrative case is therefore on the order of $330, or about 58% of the current ASC payment. The real per-case figure at your center depends on your actual weights and case mix; the point is the order of magnitude, and that the spread between the two paths dwarfs any plausible annual update.

Run your 2027 case-mix model both ways: current methodology, and H.R. 8091’s parity formula. The gap between those two numbers — not the 2.6% on the headline — is what this year’s policy fights are worth to your center.