Professional Part B Medicare fees are on the upswing overall, but site of service will be a huge factor in reimbursement in 2026. The proposed 2026 Medicare physician fee schedule, released today, boosts the Part B conversion factor for CY 2026, adds billing opportunities for behavioral health services, previews new codes and updates the agency's quality reporting programs.
CMS also signaled other notable priorities, including significant changes to the way the agency calculates rate-setting on a per-code basis, a new payment model called the Ambulatory Specialty Model (ASM) that's focused on the treatment of heart failure and lower back pain, telehealth flexibilities and more.
New for CY 2026, CMS is proposing a separate conversion factor for clinicians and groups that operate as an alternative payment model (APM). The Qualifying APM groups will see a +3.8% conversion factor increase, while non-APM clinicians are in line for a +3.3% jump, according to the proposed 2026 Medicare physician fee schedule.
The proposed fee schedule reverses a string of annual rate cuts for professional providers. Final CY 2025 fees were down 2.8%, and trade groups lobbied CMS and Congress over the past year to halt the downward trend. Earlier this month, lawmakers authorized a 2.5% increase for professional fees in the President Trump-backed spending bill, which accounts for most of the year-to-year increases.
But CMS also is upping the conversion factor with a budget neutrality adjustment of 0.55% for each of the rates in 2026, and the non-APM conversion factor has a further adjustment of 0.25% while the APM gets an additional 0.75% boost, based on statute.
Calculating the proposed CY 2026 PFS conversion factor (CF)
| CY 2025 non-APM CF |
CY 2026 non-APM CF (proposed) |
YTY % change |
| $32.3465 |
$33.4209 |
+3.3% |
| CY 2025 Qualifying APM CF |
CY 2026 Qualifying APM CF (proposed) |
YTY % change |
| $32.3465 |
$33.5875 |
+3.8% |
| CY 2025 anesthesia CF |
CY 2026 anesthesia CF |
YTY % change |
| $20.3178 |
$20.5728 |
+1.3% |
*Note: All rates are proposed, not final
CMS also is proposing critical changes to how it values codes and services. The agency proposed an "efficiency adjustment" to the work portion of relative value units (RVU) that looks at "the past five years of the Medicare Economic Index (MEI) productivity adjustment percentage," according to the rule. Historically, CMS has used surveys furnished by the AMA Relative Value Scale Update Committee (AMA RUC) "to estimate practitioner time, work intensity, and practice expense."
Similarly, CMS is proposing substantial changes to its valuation of practice expense (PE) RVUs. "Specifically, we are proposing to recognize greater indirect costs for practitioners in office-based settings compared to facility settings ... we believe that the allocation of indirect costs for PE RVUs in the facility setting at the same rate as the non-facility setting may no longer reflect contemporary clinical practice."
The changes to the RVU valuation are projected to significantly skew the levels of reimbursement for specialties, depending on the site of care. For example, family practice providers are expected to gain a 6% payment boost in the non-facility setting in 2026, in contrast to a -9% cut in the facility setting, according to Table 92 of the proposed rule. Nurse practitioners would see a -9% fee cut in the facility, compared to a 5% increase in the non-facility setting.
New code preview
Watch for 117 new codes spread across the E/M, surgery, radiology and medicine chapters of your 2026 CPT manual. The proposed rule gives you a first look at codes for services covered by the physician fee schedule, along with CMS’ initial decision on whether to cover a new service and proposed relative value units (RVU).
For example, you’ll find two new remote physiologic monitoring codes in the E/M chapter of your next CPT manual. CMS intends to cover both codes. It did not assign work RVUs to the code with the descriptor, “Remote monitoring of physiologic parameter(s) (that is, weight, blood pressure, pulse oximetry, respiratory flow rate); device(s) supply with daily recording(s) or programmed alert(s) transmission, 2-15 days in a 30-day period.”
However, it did assign .39 work RVUs to the code with the descriptor, “Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring 1 real-time interactive communication with the patient/caregiver during the calendar month; first 10 minutes.”
Other services that will have permanent codes in 2026 include osteotomy(ies) of the femur or tibia, including the fibula; 44 revascularization procedures, nine prostate biopsy services; a percutaneous lumbar decompression service with an add-on code for each additional interspace; three surface radiation therapy services; and four new remote therapeutic monitoring services in the Medicine chapter.
Complexity of care add-on code might move into the home setting next year. CMS intends to allow providers to report the code with home/residence services (99341-99345 and 99347-99350), according to the Evaluation and Management (E/M) Visits section of the proposed rule.
Global surgery period: Still in limbo
The debate over global surgery payments isn’t going away any time soon, based on a recent HHS Office of Inspector General report and the proposed rule. CMS again requested comments on how to improve the accuracy of payments for services with a 90-day global surgery period, which suggests that the agency wants to do more than collect data.
According to a fact sheet released with the proposed rule CMS wants to determine “what next steps we could take to improve the accuracy of payment for global surgical packages.”
The agency is also requesting input on “current practice standards and division of work between surgeons and providers of post-operative care,” the agency wrote.
Quality Payment Program (QPP)
In its ninth year, the QPP is not changing much for MIPS participants, with scoring metrics remaining the same as last year with a performance threshold of 75 points. Advanced APM participants – Qualifying APM Participants (QP) – still get an 0.75% increased physician fee scheduel update.
Some MIPS measures are added, subtracted and changing; e.g., in the Improvement Activities performance category, CMS is removing the Achieving Health Equity subcategory and swapping in a new Advancing Health and Wellness subcategory.
CMS is still pushing the Multiple Values Pathways (MVP) as the next phase of QPP and says it’s “committed to our goal of ensuring more meaningful participation in the Quality Payment Program through MVPs.” The agency proposes six new MVPs (Diagnostic Radiology, Interventional Radiology, Neuropsychology, Pathology, Podiatry, and Vascular Surgery), and will update the MVP group registration process to add a multispecialty self-attestation requirement, and continue to allow multispecialty groups with a small practice designation to use the MVP group reporting option.
Medicare Shared Savings
In keeping with recent comments out of CMS, the agency is proposing to reduce the length of time an ACO can participate in a one-sided model of the BASIC track, starting in 2027, to a maximum of five rather than seven performance years.
CMS also proposes “flexibility” on the requirement that Shared Savings ACOs have 5,000 assigned Medicare fee-for-service (FFS) beneficiaries, allowing fewer assignees in their initial benchmark years, while also capping their shared savings and shared losses at a lower amount in that period.
The health equity adjustment is being removed, as is the APP Plus quality measure, Screening for Social Drivers of Health.
CMS also announced some Requests for information (RFI), including one to address the use of Fast Healthcare Interoperability Resources (FHIR)-based electronic clinical quality measures (eCQM) in quality reporting and payment programs.
Ambulatory Specialty Model
CMS proposes through the Innovation Center an Ambulatory Specialty Model, which will “test whether adjusting payment for specialists based on [specialists’] performance on targeted measures of quality, cost, care coordination, and meaningful use of certified electronic health record (EHR) technology (CEHRT) results in enhanced quality of care and reduced costs through more effective upstream chronic condition management.”
This would be a mandatory model assigned to a select group of specialists in certain regions, with a focus on “the chronic conditions of heart failure and low back pain.”
New behavioral health add-on services
CMS adds three optional add-on codes for advanced primary care management (APCM) services to “facilitate providing complementary BHI [behavioral health intervention] services by removing the time-based requirements of the existing BHI and CoCM [Collaborative Care Model] codes,” which they believe will “reduce burden on practitioners by reducing the documentation requirements for billing.”
The placeholder codes are GPCM1, based on 99492 (Initial psychiatric collaborative care management, first 70 minutes); GPCM2, based on 99493 (Subsequent psychiatric collaborative care management, first 60 minutes) “for CoCM services delivered to patients also receiving APCM services”; and GPCM3, “for general behavioral health integration services based on CPT code 99484 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time).”
CMS also proposes to expand eligibility for the digital mental health treatment (DMHT) codes G0552, G0553 and G0554 to cover use of digital therapy devices for attention deficit hyperactivity disorder (ADHD).