CMS Releases Final CY 2026 Hospital Outpatient Prospective Payment System (OPPS): Implications for Nuclear Medicine

On November 21, the Centers for Medicare and Medicaid (CMS) released its final rule for the CY 2026 Hospital Outpatient Prospective Payment System (OPPS). CMS also released a fact sheet and a press release summarizing the rule. These policies will take effect January 1, 2026, unless otherwise noted. SNMMI members can find a Hospital Rate APC Chart comparing October 2025 and 2026 rates, as included in the final OPPS rule on our website.

Diagnostic Radiopharmaceutical Packing Threshold:

CMS finalized the updated per-day cost threshold of $655 (up from $630). CMS declined requests to freeze the threshold for two years but indicated it will monitor unintended pricing incentives, including manufacturers positioning prices just above the threshold.

Continued Use of Mean Unit Cost (MUC) Instead of Average Sale Price (ASP):

CMS again declined to adopt ASP-based payment for separately payable diagnostic radiopharmaceuticals. The Agency reiterated that universal ASP reporting does not exist yet for these products and that current submissions often contain erroneous or extreme values, raising the risk of substantial overpayments if ASP were used under current conditions. CMS noted that ASP could be adopted in the future only if manufacturers submit complete, validated, and descriptor-aligned data that allow accurate comparison across products.

SNMMI is disappointed by this decision. We believe that paying for non-pass-through diagnostic radiopharmaceuticals using the arithmetic mean unit cost is inappropriate, as it does not reliably reflect the average price of a non-pass-through separately payable diagnostic radiopharmaceutical. While MUC reflects hospital-reported claims data, it often fails to capture actual acquisition costs due to variability in hospital reporting practices and the lag when costs are incurred and their appearance in cost reports. MUC calculations also rely on cost-to-charge ratios (CCRs) derived from broad categories of services and items, which are poorly suited to estimating the cost of individual products. Moreover, these CCR-based estimates often rely on data that are several years old. In contrast, ASP data are updated quarterly and provide a more current, transparent, and product-specific measure of actual acquisition costs.

SNMMI will continue to work with our partners to engage CMS on this important reimbursement issue.

Add-On Payment for Tc-99m from Domestically Produced Mo-99:

Beginning in CY 2026, CMS finalized a $10 per-dose add-on for Tc-99m derived from domestically produced Mo-99. CMS is also establishing a new HCPCS code C9176 for these qualifying doses.

SNMMI supports the addition of this add-on payment. We encourage CMS to provide clear operational guidance on the documentation hospitals must maintain to verify that at least 50 percent of Mo-99 in TC-99m generators is sourced domestically. CMS should also consider implementing periodic reviews of the $10 add-on payment to ensure it remains adequate as domestic production capacity grows and costs evolve, and to ensure it sufficiently covers the per-dose cost of implementing full-cost recovery pricing, consistent with CMS s stated goal. Additionally, while CMS has focused on domestic production of Tc-99m as the primary imaging radioisotope, we urge CMS to expand the add-on payment policy to include Xe-133 and I-131 radiopharmaceuticals derived from domestically produced Mo-99, given their critical role in lung, brain, and thyroid imaging.

Reassignment of CPT Codes:

CMS reviewed CPT 78803 and found the geometric mean cost has fallen to approximately $585, primarily due to last year's policy change to pay certain diagnostic radiopharmaceuticals that were previously packaged separately. CMS proposed and is now finalizing reassignment of: CPT 78803 to APC 5592. SNMMI strongly opposed the move, citing the 57% payment reduction, ongoing cost-reporting instability following radiopharmaceutical unpackaging, and the fact that comparable SPECT procedures remain in APC 5593. Despite these concerns, CMS finalized the reassignment, stating the lower geometric mean cost supports placement in a lower-level APC. CMS noted it will reevaluate this APC assignment in the next rulemaking cycle.

Several other related nuclear medicine procedures experienced similar reductions due to the same radiopharmaceutical unpackaging policy or cost-reporting shifts. These include CPT 78432, 78802, and 78804, all of which also showed significant decreases in geometric mean cost leading to APC reassignments. CMS acknowledged stakeholders' concerns but maintained that its annual recalibration process must rely on the most current claims data available.

CMS also finalized the reassignment of CPT 93017 to APC 5722 despite SNMMI's concerns about an expected ~29% payment decrease and requests to maintain payment at $311.40. CMS explained that annual OPPS recalibration requires grouping services based on clinical and resource similarity, consistent with statutory requirements and the two-times rule. Updated claims data for the final rule showed a geometric mean cost of $271.62 for CPT 93017, which falls squarely within the APC 5722 cost range ($165-$298). CMS therefore determined that the code is appropriately placed in this lower-level APC and finalized the reassignment, noting it will continue monitoring the APC series as additional data becomes available in future years.

In response to stakeholder comments regarding CPT 78800, CMS clarified that the correct APC assignment for CY 2026 is APC 5591 (Level 1 Nuclear Medicine and Related Services) with status indicator S. CMS confirmed that the alternative APC (5573) shown in some proposed rule tables was a formatting artifact, and that the correct assignment is reflected in final Addendum B and D1.

Finally, CMS also finalized two new codes relevant to nuclear medicine:

• C9176 (Tc-99m from domestically produced non-HEU Mo-99, [minimum 50 percent], full cost recovery add-on, per study dose -see more above), effective January 1, 2026.
• A9616 Gallium ga-68 gozetotide (gozellix), diagnostic, 1 millicurie, a new HCPCS code, effective October 1, 2025, for radiopharmaceutical supply

SNMMI will continue to engage with CMS to protect fair reimbursement for nuclear medicine procedures and to advance data-driven, specialty-appropriate policies.