What’s on the Horizon for CY 2026 in the Medicare PFS?
Article Reference Code: NAMAS.11.14.2025
Written by: Rachel V. Rose, JD, MBA
It’s that time of the year when the focus of healthcare providers, insurers and health care claims clearinghouses begins to heighten because January 1 is on the horizon, which means potential changes to the CY 2026 Medicare Physician Fee Schedule (PFS). In light of the impending New Year, here are some items to keep in mind when transitioning.
On July 14, 2025, the Centers for Medicare & Medicaid Services (CMS) issued its annual proposed rule soliciting comments on proposed policy changes for under the PFS and other Medicare Part B items, effective January 1, 2026.[1] (90 Fed. Reg. 32352 (Jul. 16, 2025)). One of key items of interest is the conversion factors. Pursuant to statute, beginning in CY 2026, two separate conversion factors will apply: (1) qualifying alternative payment model (APM) participants (QPs); and (2) non-QP physicians and practitioners. “By statute, QPs are those that meet certain thresholds for participation in an Advanced APM.”[2] Advanced APM models translate into patient centered care with a focus on quality and cost accountability. Here’s the monetary impact.
The update to the qualifying APM conversion factor for CY 2026 is +0.75 percent while the update to the nonqualifying APM conversion factor for CY 2026 is +0.25 percent. The changes to the PFS conversion factors for CY 2026 include these updates as required by statute, a one-year increase of +2.50 percent for CY 2026 stipulated by statute, and an estimated +0.55 percent adjustment necessary to account for proposed changes in work RVUs for some services. The proposed CY 2026 qualifying APM conversion factor of $33.59 represents a projected increase of $1.24 (+3.8%) from the current conversion factor of $32.35. Similarly, the proposed CY 2026 nonqualifying APM conversion factor of $33.42 represents a projected increase of $1.07 (+3.3%) from the current conversion factor of $32.35. Per statutory requirements, we are also proposing updates to the geographic practice cost indices (GPCIs) and malpractice RVUs.[3] (emphasis added).
One way to keep quality and costs under control, while improving patient outcomes is through chronic care management services (CCMS). Beginning in 2015, Centers for Medicare and Medicaid Services (CMS) began reimbursing providers for CCMS furnished to Medicare beneficiaries with 2 or more chronic conditions with the objective of improving patient health outcomes.[4] Chronic condition management (CCM) and remote patient monitoring (RPM) are two common types of CCMS.[5] Providers and third-party entities who render RPM and CCM services should also stay abreast of CMS proposed coding changes. For example, CMS is proposing dual changes to address CPT 99454 (device supply and data transmission). New code (99XX4) covers RPM services when 2 to 15 days of data are collected in a 30-day period, while revised code (99454) would represent the 16 to 30-days of data collection.[1]
Another item is the proposed flexibility of split/shared Evaluation and Management (E/M) visits in 2026, which could be predicated on either time or the performance of medical decision-making (MDM) by the billing practitioner. From a practical standpoint, this is full of potential landmines and adequate documentation must be present to substantiate the code and ensure that an appropriate modifier is applied.
As a reminder, physicians or other qualified health professionals that serve in an attending capacity in academic medical settings must be present during the key portions of a visit or a procedure. Notably, even during COVID-19, there were limits on residents, interns and fellows, including the severity of the condition, the level of E/M code that they could render and the type of practice. So while the notion is that attendings being present for “key portions” reflects a return to “pre-PHE [public health emergency]” rules there were still requirements in place for attendings even through the PHE, especially with certain visits and services.
In sum, making sure that providers and coders alike are adequately trained, that electronic health record systems are updated and that potential areas of fraud, waste and abuse (e.g., upcoding) are considered is a prudent approach to both implementing the proposed changes and cultivating a culture of compliance.
[1] See Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule (CMS-1832-P), https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-pfs-proposed-rule-cms-1832-p.
[1] Ibid.
[1] Ibid.
[1] 79 Fed. Reg. 67548, 67715-16 (Nov. 13, 2014).
[1] CMS, MLN9099188, p. 3 (June 2025).
[1] NRHA, What Medicare’s 2026 proposed rule signals for remote care (Aug. 12, 2025), https://www.ruralhealth.us/blogs/2025/08/what-medicare’s-2026-proposed-rule-signals-for-remote-care#:~:text=New%20code%20(99XX5):%20Would,smaller%20touchpoints%20without%20losing%20value.
[1] NRHA, What Medicare’s 2026 proposed rule signals for remote care (Aug. 12, 2025), https://www.ruralhealth.us/blogs/2025/08/what-medicare’s-2026-proposed-rule-signals-for-remote-care#:~:text=New%20code%20(99XX5):%20Would,smaller%20touchpoints%20without%20losing%20value.
If you have questions about this article or it’s content- Click here to connect with Rachel on LinkedIn
Rachel V. Rose, JD, MBA (Houston, Texas) is a disciplined, empathetic, and tenacious attorney advocating for and winning desired legal outcomes for national and international clients. Ms. Rose’s practice includes compliance, transactional, and litigation matters primarily related to healthcare, cybersecurity, securities, the False Claims Act, and Dodd-Frank. She is also affiliated with Baylor College of Medicine where she teaches bioethics, holds a variety of leadership positions, and is extensively published, as well as being sought after as a presenter and expert.
Disclaimer:
The NAMAS Blog features content written by both NAMAS staff and guest contributors. Guest contributors may present opinions or perspectives that differ from those officially instructed or encouraged by NAMAS. We believe in providing space for a range of informed viewpoints to foster dialogue, reflection, and deeper understanding within the auditing and compliance community.
Some contributors may use artificial intelligence (AI) tools in the development of their content. The decision to incorporate AI is left to the discretion of the author and does not reflect an endorsement or directive from NAMAS.
If you have questions, comments, or concerns about a specific blog post, we encourage you to contact the individual author directly. Their name and contact information are provided at the end of each post.
