Key Medicare Payment Proposals: 2026 Physician Fee Schedule

The proposed 2026 Medicare Physician Fee Schedule released in early July would update the PFS conversion factor from $32.3465 to $33.5875 for qualifying alternative payment model (APM) participants and $33.4209 for nonqualifying 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 nonfacility services are projected to increase 5%.

Key highlights from the proposed rule relevant to cardiovascular clinicians include:

• Ambulatory Specialty Model: Of note, the CMS Innovation Center is proposing a mandatory five-year Ambulatory Specialty Model aimed at holding specific specialists who have historically treated at least 20 original Medicare patients with heart failure (HF) and who are within selected core-based statistical areas or metropolitan divisions financially accountable for management of congestive HF and low back pain. The model looks to reward specialists for effective disease management, adhering to clinical guidelines for care and coordinating with other providers involved in the management of their patients' care.
• Efficiency Adjustment: The rule proposes an efficiency adjustment to the intra-service times and work relative value units (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. Using the Medicare Economic Index productivity adjustment for the last five years cumulatively applied, the rule proposes a 2.5% reduction to the intra-service time and work RVU of all non–time-based codes or codes that are otherwise excluded. This is the first proposal of its kind and will require the ACC's attention and collaboration with the American Medical Association (AMA) and other societies to address.
• 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 RVU of 14.00. The ACC will vigorously work to keep this reduction from being implemented. Learn more and read a joint statement issued by the ACC, Heart Rhythm Society (HRS), and Society for Cardiovascular Angiography and Interventions.
• 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.

Read an ACC Advocacy deep dive on payment policy, rate setting and quality provisions from the proposed rule.

Keywords: Cardiology Magazine, ACC Publications, Health Policy, Policy, Fee Schedules, Centers for Medicare and Medicaid Services, U.S., ACC Advocacy