The proposed 2026 Medicare Physician Fee Schedule (PFS) includes a proposal to reduce the physician work relative value unit (RVU) for performing a left atrial appendage closure procedure (LAAO) from 14.00 to 10.25, further lowered to 9.99 when accounting for a proposed efficiency adjustment reduction. This proposed revaluation was based on a review by the American Medical Association (AMA) Relative Value Scale Update Committee (RUC) that makes recommendations to the Centers for Medicare and Medicaid Services (CMS). 

The ACC, along with the Heart Rhythm Society (HRS) and the Society for Cardiovascular Angiography and Interventions (SCAI), met with CMS twice since the RUC issued its work RVU recommendations regarding LAAO (CPT code 33340) last year, expressing concerns with the survey used to inform this recommendation. The societies urged CMS to maintain the current value or use one of several more accurate and representative RVU suggestions based on crosswalks to existing, comparable codes until it can be reevaluated appropriately. Instead, CMS opted to include the recommended reduction in the proposed rule.

A joint statement on the proposed cut has been issued, stating that "cutting reimbursements for procedures that reduce strokes, such as the 27% in the proposed rule to LAAO, will only increase the risk of hospitalization and long-term disability for vulnerable patients." Read the full statement.

Other policy changes proposed in the PFS would compound and extend reductions in total RVUs for LAAO. The table below lays out how the compounding reductions will ultimately affect LAAO reimbursement over the next two years.

LAAO Reimbursement Reduction Explained:

1. The full impact of changes to work RVUs and other policies would be a roughly 35% reduction to LAAO in 2027 (see 2027 row).
2. This stems in part from the 27% reduction in work RVUs from 14.00 to 10.25 (see 2026 row).
3. CMS also proposes an efficiency adjustment reducing most services by 2.5%, assuming the fee schedule does not adequately incorporate care evolutions through traditional reviews. This proposed adjustment makes no exception for services like LAAO that have already been revalued (see 2026 row).
4. With more physician practices moving toward hospital employment/integration, CMS believes this trend is reducing overhead practice costs. The proposed PFS formula would reduce indirect practice expense (PE) attributed to many services provided in hospitals. This reduction would lower affected services by about 10% of their current total RVU (see 2027 row).
5. In addition to the broad indirect PE policy change, PE for LAAO would also go down because a portion of indirect PE is directly linked to work RVU. This reduces the current total RVU by about an additional 5% (see 2027 row).
6. Similarly, the liability RVU is also directly linked to the work RVU and would be reduced (see 2026 and 2027 rows).
7. Because these multiple reductions exceed a 20% total reduction in RVUs, the cuts will be phased in over two years. For 2026, the total reduction would be 19% from 2025 (see 2026 row). The rest of the large cut would be implemented in 2027 (see 2027 row). The PE RVUs increase slightly for 2026 as the mechanism to limit the total reduction to 19%, before dropping to capture the full 35% in 2027.

More Background on the RUC Recommendation

The RUC is a volunteer group of physicians and other health care professionals that provide recommendations to CMS on the RVUs for services provided under the Medicare PFS.

A RUC subcommittee called the Relativity Assessment Workgroup (RAW) is tasked with identifying potentially misvalued services within the Medicare PFS. The RUC may develop new RVU recommendations if deemed necessary.

In 2024, the RAW determined that CPT code 33340 (left atrial appendage closure with endocardial implant) needed to be reevaluated, and the code was surveyed by the relevant specialty societies, including the ACC, in April 2024. These recommendations were provided to CMS for review and consideration during the development of the proposed 2026 Medicare PFS.

RUC surveys rely heavily on comparison to other similar codes. The valuation of one code relative to another within the system is the basis of the RVU system used for Medicare Part B reimbursement. When taking RUC surveys, participants are asked to compare the service being evaluated to a reference service list (RSL) of related codes. Unfortunately, in the case of CPT code 33340, a number of related codes were not included in the RSL because they were also being reevaluated and were not yet formally updated by CMS.

The ACC, HRS and SCAI had urged the RUC to delay the reevaluation until the appropriate codes could be included in the survey, but these efforts were unsuccessful. As expected, the survey yielded poor data and resulted in a dramatic reduction in work RVU for LAAO from 14.00 to 10.25.

The ACC and its partners will work vigorously to ensure this proposed reduction is not finalized.

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services, U.S., Current Procedural Terminology, Fee Schedules, American Medical Association