The Centers for Medicare and Medicaid Services (CMS) has released the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, updating the PFS conversion factor from $32.3465 to $33.5875 for qualifying alternative payment model (APM) participants and $33.4209 for non-qualifying APM participants, increases of 3.8% and 3.3%, respectively. This duality is required by current law. These conversion factors include the 2.5% increase passed in recent budget reconciliation legislation.

The overall reimbursement for cardiovascular services is projected to increase roughly 1% compared with 2025, including changes to policies and individual service values. Individuals and groups will see different impacts depending on patient populations and services offered. Due to other provisions discussed below, facility-based services for cardiology are projected to decline 6% and non-facility services are projected to increase 5%.

Key proposals relevant to cardiovascular clinicians regarding payment policy, rate setting and quality provisions are below.

Physician Fee Schedule

• Left Atrial Appendage Closure: Despite efforts to delay revaluation of the Left Atrial Appendage closure code 33340 due to a restricted and flawed survey or propose an alternative value, the proposed rule accepts the AMA Relative Value Scale Update Committee (RUC)-recommended value of 10.25, a nearly 27% reduction from the current work relative value unit (RVU) of 14.00. The ACC will vigorously work to keep this reduction from being implemented.
• PCI: The PCI code family was revised at CPT and then resurveyed at the RUC in April 2024 for implementation in 2026. CMS accepted the RUC-recommended values for all 12 codes. Several codes were reduced while others saw an increase in their work RVU. New codes were created for more complex stent cases and revascularization of a chronic total occlusion to allow for more accurate valuation.
• Lower Extremity Revascularization (LER): The LER code family was revised at CPT from 16 codes to 46 codes. All RUC-proposed values for the new codes were accepted. CMS requests comments on potentially creating G codes for high-cost supplies.
• AI-Coronary Plaque Assessment: A new code for coronary plaque assessment was created at CPT and the RUC-recommended work RVU value is proposed by CMS. The agency proposes a crosswalk for the practice expense component of the code, similar to what was done for fractional flow reserve CT.
• Remote Physiologic Monitoring: Several new remote monitoring codes were created and existing codes resurveyed. As the surveys did not reach the minimum response threshold, CMS proposes to maintain the existing code values over the lower RUC recommendations and value the new codes using ratios related to those existing codes. The code family will be resurveyed in January 2028.
• Baroreflex Activation Therapy (BAT): Seven of the eight newly created codes for BAT are proposed at the RUC recommendations. One programming code was moderately reduced via crosswalk to an existing code.
• Efficiency Adjustment: The rule proposes an efficiency adjustment of –2.5% to the intra-service times and work RVUs of nearly all non–time-based codes in the PFS. The proposal notes that there are efficiencies in performing medical services that accrue over time and are not captured in the normal process of developing the time and work RVUs. The adjustment represents a five-year look back at the productivity adjustment derived from the Medicare Economic Index. The proposal would apply the efficiency adjustment every three years moving forward if finalized.
• Practice Expense (PE): The proposed rule includes work and/or PE values for new/revised codes for LER, BAT, CT coronary plaque assessment and remote physiologic monitoring. More information is available in supporting data tables on values for these and all codes.
• Physician Payment Information Survey (PPIS): CMS does not propose any updates to indirect costs in the fee schedule based on data collected through the AMA PPIS at this time.
• Indirect PE: CMS proposes a significant update to its payment methodology and the way it pays for indirect PE. Noting evolving trends in physician practice from independent practice to hospital employment or integration, CMS posits that allocation of the same indirect PE for services performed in the hospital as the office may no longer be accurate. Therefore, for services valued in the hospital setting, CMS proposes reducing the portion of indirect PE allocated based on work RVUs by 50% starting in 2026. This change produces total RVU reductions of around 10% for facility-based services, such as pacemaker implants, TAVR, PCI, ablation, etc.

Budget neutrality-related cuts have significantly impacted physicians in recent years. The conversion factor was reduced by 2.83% in 2025, 2% in 2023, 0.8% in 2022 and 3.3% in 2021. While CMS is proposing a more than 3.5% increase to the conversion factor for 2026, this increase will be largely offset by a proposed efficiency adjustment reduction that will disproportionately affect procedural and diagnostic services. Combined with the failure to account for significant inflation in practice costs, this trend creates long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating physicians and services.

The ACC, along with other medical societies, has aligned with the American Medical Association (AMA) on a set of principles to guide advocacy efforts on Medicare physician payment reform. The College recently joined other medical specialty organizations in a statement addressed to congressional leaders, urging them to pursue long-term reform. In the previous Congress, legislation was introduced to include an annual inflationary update linked to the Medicare Economic Index and to raise the budget neutrality threshold to help reduce year-to-year cuts. The ACC is actively working to introduce similar legislation this Congress.

The College will also continue to explore and promote approaches to stabilize the health care system and foster a successful, widespread transition to value-based care that reflects the needs of cardiovascular patients and clinicians in every setting. Learn more about ACC's ongoing efforts to establish sustainable Medicare payment practices and how to get involved.

More highlights from the proposed rule include:

Ambulatory Specialty Model

• The CMS Innovation Center is proposing a mandatory five-year Ambulatory Specialty Model (ASM) aimed at holding specialists who historically treated at least 20 Original Medicare patients with heart failure (HF) and within selected core-based statistical areas (CBSAs) or metropolitan divisions financially accountable for management of chronic conditions including congestive HF and low back pain.
• As proposed, all ASM participants will be engaged in a two-sided risk arrangement with payment adjustments of –9% to +9% in the first payment year.
• The model will utilize the Merit Based-incentive Payment System (MIPS) Value Pathways (MVPs) to assess physician performance on quality, cost, technical interoperability and improvement activities, which are largely focused on care coordination with primary care.
• The selected CBSAs or metropolitan divisions will be determined in the future and will include approximately 25% of CBSAs.
• Clinicians participating in the ASM will be exempt from MIPS requirements during ASM performance years.
• The ASM is proposed for the performance period from Jan. 1, 2027, through Dec. 31, 2031, and payment period from Jan. 1, 2029, through Dec. 31, 2033.

Telehealth Provisions

• Without action by Congress, the originating site flexibilities for telehealth will end Sept. 30, 2025.
• Cardiac rehabilitation services are proposed to be permanently added to the telehealth list beginning in 2026 using updated criteria to streamline inclusion of services.
• CMS proposes to allow direct supervision for the "immediate availability" of supervising clinician via audio/video real-time communication of most services that do not have 10- or 90-day global periods.
• CMS proposes to no longer allow teaching physicians to use audio/video real-time communications technology when the resident furnishes Medicare telehealth services in all teaching settings.
• The 2025 PFS final rule extended a pandemic-era policy permitting distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through the end of 2025. There is no mention of this provision in the 2026 proposed rule. This may reflect the impending expiration of telehealth flexibilities.

2026 QPP Performance Period

CMS is proposing several updates to the Quality Payment Program (QPP) and Medicare Shared Savings Program (MSSP) for 2026.

• The proposed rule maintains the performance threshold at 75 points through the 2028 performance period/2030 MIPS payment year.
• CMS proposes a total of 190 quality measures for the 2026 performance period by addressing changes to 32 existing MIPS quality measures, removing 10 quality measures, and adding five quality measures, including two electronic clinical quality measures (eCQMs).
• Four measures were removed from the cardiology quality measure set.
• In alignment with proposals to update the quality measure and improvement activity inventories, the agency proposes six new MVPs to be available for reporting in the 2026 performance period, along with modifications to all 21 existing MVPs.
• Modifying the previously finalized Advancing Care for Heart Disease MVP within the quality performance category, the proposed rule removes one quality measure and three improvement activities. In addition, quality measures have been placed into "clinical groupings."
• Shifting the responsibility for defining group composition (single or multispecialty) from CMS to the group itself, the proposed rule requires attestation during MVP registration rather than relying on Medicare claims. The definitions for single specialty groups, multispecialty groups, and subgroups are being updated to reflect a broader understanding of clinical focus and to align more clearly with MVP reporting structures.
• CMS proposes updating the benchmarking methodology for administrative claims quality measures to align with the methodology for cost measures, beginning with the 2025 performance period/2027 MIPS payment year.
• The proposed rule modifies the Total Per Capita Cost measure candidate event and attribution criteria.
• CMS proposes a two-year informational-only feedback period for new cost measures beginning with the 2026 performance period.
• Minor changes to the Cost, Quality, Improvement Activities and Promoting Interoperability performance categories have been proposed. For the 2026 performance period/2028 MIPS payment year, the scoring weights are as follows: 30% for the quality performance category; 30% for the cost performance category; 15% for the improvement activities performance category; and 25% for the promoting interoperability performance category.

Join Us at ACC Legislative Conference

Not long before CMS is slated to release the Medicare PFS final rule, ACC leaders and other health policy experts will discuss federal legislative and regulatory topics at ACC Legislative Conference 2025, taking place Oct. 5-7 in Washington, DC.

Don't miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill. Register today.

• CMS proposes a revision to MSSP regulations that includes changing references to "health equity benchmark adjustment" to "population adjustment," which they state more accurately reflects the population captured. 
• CMS seeks public comment on Core Elements in an MVP, well-being and nutrition measures, procedural codes for MVP assignment, transition toward digital quality measurement, and evaluating how clinicians exchange health information.

Additional information on the proposed rule can be found in the Medicare PFS Press Release, Fact Sheet, and Addenda, in addition to the MSSP Fact Sheet and QPP Fact Sheet. ACC Advocacy staff will continue to provide more detailed information on elements of the proposed rule in the weeks ahead and develop comments for submission within the 60-day comment period. Look for updated information on ACC.org/Advocacy and in upcoming issues of the ACC Advocate newsletter.

Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention

Keywords: Fee Schedules, Centers for Medicare and Medicaid Services, U.S., ACC Advocacy, Delivery of Health Care, Percutaneous Coronary Intervention, Atrial Function, Left, Atrial Appendage