The Proposed Rule issued by the Centers for Medicare and Medicaid Services (CMS) for payments under the 2026 Medicare Physician Fee Schedule (MPFS) contains an increase from the current 2025 rate.
Sandy Coffta.
There will be two different fee schedules determined by a provider’s participation status in Alternative Payment Models (APM). The Conversion Factor (CF) in the 2026 Proposed Rule is $33.5875 (up 3.83%) for Qualified Professionals (QP) or $33.4209 (up 3.32%) for non-QP’s, compared with the $32.3465 currently in use.
Both CF calculations apply a positive 0.55% budget neutrality factor and a 2.50% increase that was contained in the budget act (OBBBA) passed in July, to arrive at a baseline CF of $33.3375. However, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA 2015) contained a requirement that participants in APMs would receive an additional 0.75% annual update beginning in 2026, while non-APM participants would receive a 0.25% annual update. Thus, the 2026 CF proposed for QPs becomes $33.5875 and for non-QP’s becomes $33.4209.
The published CMS estimates indicate that diagnostic radiology and nuclear medicine will be negatively impacted (-2% and -1%, respectively) by the PFS rule, but interventional radiology would see a 2% increase. The rate of impact varies significantly depending on the site of service, as follows:
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Subspecialty
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Imaging Center Global Fee
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Hospital Professional Fee
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Combined Impact
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Interventional Radiology
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7%
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-7%
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2%
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|
Nuclear Medicine
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1%
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-3%
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-1%
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Radiology
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1%
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-3%
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-2%
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Offsetting the rate increase?
The MPFS contains language that shifts reimbursement away from services provided in a facility (hospital) setting and toward office-based services. Historically, work RVU (wRVU) values that reflect the physician’s services have been the same regardless of the site of service. As a result of this rule, radiology services provided in imaging centers and office-based labs (OBL) could become more lucrative than hospital work.
The proposed rule would “reduce the portion of the facility PE RVUs allocated based on work RVUs to half the amount allocated to non-facility [practice expense] PE RVUs.” This would create a redistribution of value from facility-based services to non-facility-based services.
In addition, the CMS proposes to apply an Efficiency Adjustment to the work RVU and corresponding intraservice portion of physician time for non-time-based services. As proposed, this would generally apply to all codes except time-based codes such as Evaluation and Management (E/M) services.
“Included code families represent the procedures, diagnostic tests, and radiology services that CMS expects to accrue efficiencies over time as changes in medical practice occur, including changes in clinician expertise, workflows, and technology,” according to the CMS.
For radiology practices, these adjustments could offset much of the increase in the fee schedule CF. We will be analyzing which procedures would be affected and assessing the impact on radiology.
Expiring regulations
A Continuing Resolution (CR) passed by Congress in March 2025 extended the 1.0 work floor factor that is used to calculate the geographic adjustment of the Medicare fee schedule through September 30, 2025. This Geographic Adjustment Factor (GAF) is mentioned here as it is scheduled to expire and could impact radiology practices’ reimbursement before the end of 2025 if it is not extended. There is no permanent change to the 1.0 work floor in the Proposed Rule for 2026. Refer to our article What Else is in the Medicare Proposed Rule for 2025? for a full explanation of the GAF.
Supervision requirements
The MPFS Proposed Rule would make permanent the supervision flexibilities granted in 2020 during the COVID-19 pandemic that are due to expire at the end of 2025. Physician offices and independent diagnostic testing facilities (IDTFs) would be able to directly supervise certain diagnostic tests, such as level 2 contrast administration using real-time audio and visual interactive telecommunications technology. Note that both audio and video are required; audio-only connectivity is not sufficient.
However, as attorney Tom Greeson of ReedSmith points out in his recent article, “The excitement in the radiology community for this proposal is tempered by recent statements made by the Drugs and Contrast Media Committee of the American College of Radiology (ACR) as well as the American Society of Radiologic Technologists (ASRT) at its the Annual Governance and House of Delegates Meeting.” Those organizations are recommending that supervision should include an on-site licensed practitioner.
Quality Payment Program
In addition to fee schedule changes, the Medicare PFS covers rules that govern the Quality Payment Program (QPP). The biggest news for radiology is that six new MIPS Value Pathways (MVP) would be added, including pathways for both diagnostic and interventional radiology. The Proposed Rule includes six MIPS quality measures and three Qualified Clinical Data Registry (QCDR) quality measures, plus 11 improvement activities and one cost measure in the diagnostic radiology MVP.
Interventional radiology would have six MIPS quality measures and four QCDR quality measures, plus 19 improvement activities and 3 cost measures.
However, the Society of Interventional Radiology (SIR) is concerned that “the [MIPS Value Pathway] does not adequately reflect the diversity and highly subspecialized nature of IR.”
“SIR believes the measure set is too narrow, making it difficult for many IRs to participate meaningfully without undue burden.” The society indicates that only 3 measures are broadly applicable across the specialty, with “the remainder primarily apply to interventional radiologists subspecializing in stroke care, dialysis access, venous services, and women’s health.”
Most of the other aspects of the MIPS rules would remain unchanged for 2026, including the MIPS Performance Threshold, which is proposed to remain at 75 points through performance year 2028.
Conclusion
The Final Rule often mirrors the provisions laid out in the Proposed Rule with little change. The CF is typically modified slightly due to final calculations being applied, but there should be no significant difference. The controversial Efficiency Adjustment of 2.5% to “non-time-based procedures” is already causing a lot of discussion among physician advocacy groups, which could ultimately influence the CMS’s final decision.
Apart from the MPFS, physicians will be impacted by the changes to coverage under Medicaid and Affordable Care Act (ACA) policies that were included in the OBBBA budget bill. When individuals lose their coverage for whatever reason, practices end up providing more uncompensated care through emergency room visits.
The CMS is accepting comments on the proposed rule until September 12, 2025. We will provide our analysis of the Final Rule when it is issued.