On July 14, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) proposed rule, which includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). The proposed rule has a 60-day comment period. Final regulations will be issued on or around Nov. 1 and, unless otherwise noted, policies will be effective Jan. 1, 2026. The ACR will provide comments on the following provisions, among others.
Physician Reimbursement
- Separate updates for Qualifying Alternative Payment Model (APM) Participants (QP) and non-QP clinicians are proposed for 2026. This is the first year the CMS will implement separate conversion factors based on QP status.
- The CY 2026 qualifying APM conversion factor is projected to increase by $1.24 (3.83%) from $32.35 to $33.59. Similarly, the CY 2026 non-qualifying APM conversion factor is projected to increase by $1.17 (3.62%) from $32.35 to $33.42.
- The change to the conversion factors reflects the temporary one-year increase of 2.5% included in the budget reconciliation bill signed into law on July 4.
- The overall reimbursement for rheumatological services is projected to increase by 4% for 2025.
Efficiency Adjustment
- The CMS is proposing a -2.5% efficiency adjustment, which would apply to the work Relative Value Unit (RVU) and corresponding intraservice portion of physician time of non-time-based services.
- This would apply to all codes that are not based on time, such as evaluation and management (E/M) services, care management services and services on the Medicare telehealth list.
- The efficiency adjustment would be applied every three years; the next would be applied in CY 2029, reflecting efficiency gains measured from 2027 through 2029.
Telehealth
- The CMS is not proposing to extend the waiver of geographic and originating site requirements for Medicare telehealth services that began during the COVID-19 pandemic and are in place through Sept. 30 due to multiple extensions from Congress. Without additional congressional action, the waivers will expire Oct. 1 and telehealth originating site requirements will go back to pre-pandemic limitations on patient location.
- In the 2024 fee schedule, the CMS established a process that assigned HCPCS codes either a “provisional” or ongoing “permanent” status on the Medicare Telehealth Services List. The CMS is proposing to simplify the review process for adding new telehealth services by removing the “provisional” and “permanent” categories and focusing on whether the service can be provided via telehealth. If finalized, all services added to the Medicare Telehealth Services List will be presumed to be permanent.
G2211
- The CMS is proposing to make a minor adjustment to the G2211 complexity add-on code to allow it to extend its application to home or residence evaluation and management visits, in addition to its current usage with office/outpatient evaluation and management services.
Quality Payment Program
- The CMS is proposing to maintain the performance threshold at 75 points for CY 2026. It is proposing to maintain this threshold throughout the CY 2028 performance period.
- The CMS is not proposing to change the weights for the performance categories. The quality performance category will be weighted at 30% and the cost performance category will be weighted by 30%. The promoting interoperability and improvement activities performance categories will maintain their respective 25% and 15% weights.
- The CMS is proposing to expand the portfolio of available MIPS value pathways (MVPs) and is revising the format of each MVP (including the ACR’s Advancing Rheumatology Care MVP) to categorize the quality measures by clinical conditions or episodes of care.
- The CMS will be introducing a new format of the MVP tables in 2026 to stratify quality measures by clinical conditions and/or episodes of care for each MVP, identified as “Clinical Groupings.”
