The Centers for Medicare and Medicaid Services (CMS) has released the 2026 Medicare Physician Fee Schedule (PFS) final rule, updating the PFS conversion factor from $32.3465 to $33.5675 for qualifying alternative payment model (APM) participants and $33.4009 for non-qualifying APM participants, increases of 3.77% and 3.26%, respectively. This duality is required by current law. These conversion factors include the 2.5% increase passed in the One Big Beautiful Bill Act. The rest of the conversion factor increase stems from policy changes that reduce payment for many services.

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 7% while 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

• Efficiency Adjustment: The rule finalized an efficiency adjustment of –2.5% to the intra-service times and work relative value units (RVUs) of nearly all non–time-based codes in the PFS, citing 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 lookback at the productivity adjustment derived from the Medicare Economic Index. CMS will calculate and apply the efficiency adjustment every three years moving forward. The agency has agreed to exempt any new CPT codes created and initially valued for 2026. This amendment only applies to brand new Category I CPT codes and does not exempt existing codes that were re-valued this year. Get more details on this policy in ACC's efficiency adjustment explainer.
• Site of Service Payment Differential: A significant update to the payment methodology will change the way CMS pays for indirect practice expense (PE). Due to the rise of hospital employment or physician practice integration, CMS reduced the allocation of indirect PE for services performed in the hospital, believing those costs are now born by facilities. For services in the hospital setting, the portion of indirect PE allocated based on work RVUs will be reduced by 50% starting in 2026. This change will produce total RVU reductions of around 10% for facility-based services, such as pacemaker implants, TAVR, PCI, ablation, etc. ACC's site of service payment differential explainer provides more details.
• Left Atrial Appendage Occlusion (LAAO): Despite efforts to delay revaluation of the LAAO code 33340 due to a restricted and flawed survey, CMS finalized the American Medical Association Relative Value Scale Update Committee (RUC)-recommended value of 10.25, a nearly 27% reduction from the current work RVU of 14.00. See the full impacts in ACC's LAAO explainer. The ACC, Heart Rhythm Society, and Society for Cardiovascular Angiography & Interventions are currently resurveying this code for the next RUC meeting.
• PCI: The PCI code family was revised at CPT and then resurveyed at the RUC in April 2024 for implementation in 2026. CMS finalized 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 finalized. CMS may look to hospital outpatient cost data for practice expense in future rules.
• AI-Coronary Plaque Assessment: A new code for coronary plaque assessment was created at CPT and the RUC-recommended work RVU value has been finalized by CMS. The agency set 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 these surveys did not reach the minimum response threshold, CMS will 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 set at the RUC recommendations. One programming code was moderately reduced via crosswalk to an existing code. CMS adjusted clinical staff to be nurses for device interrogation and programming.
• Practice Expense (PE): The rule finalized 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.

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 applying a more than 3.5% increase to the conversion factor for 2026, this increase will be largely offset by the 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 AMA on a set of principles to guide advocacy efforts on Medicare physician payment reform. Earlier this year, the College joined other medical specialty organizations in a statement addressed to Congress, urging them to pursue long-term reform. Additionally, the ACC recently joined a letter to congressional leadership, urging them to stop implementation of the efficiency adjustment before Jan. 1, 2026.

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 now 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 key provisions from the final rule include:

Ambulatory Specialty Model

• CMS finalized a mandatory five-year Ambulatory Specialty Model (ASM) aimed at holding cardiologists who historically treated at least 20 original Medicare patients with heart failure (HF) within selected core-based statistical areas (CBSAs) or metropolitan divisions financially accountable for management of chronic conditions including congestive HF. A separate cohort of ASM for low-back pain was also finalized.
• All ASM participants will engage in a two-sided risk arrangement with payment adjustments of –9% to +9% to Medicare Part B reimbursements in the first payment year.
• The model will utilize the 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 announced later this year and will include approximately 25% of CBSAs.
• CMS will identify and notify preliminary ASM participants in early 2026.
• Clinicians participating in the ASM will be exempt from MIPS requirements during ASM performance years.
• The ASM is scheduled 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

• Originating site flexibilities for telehealth ended Sept. 30 after Congress failed to extend policies adopted during the COVID-19 public health emergency. Many expect these to be restored once the federal government reopens.
• Cardiac rehabilitation services have been permanently added to the Medicare telehealth list beginning in 2026 using updated criteria to streamline inclusion of services.
• CMS finalized policy 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 will no longer allow teaching physicians to use audio/video real-time communications technology when the resident furnishes Medicare telehealth services in all teaching settings. Only three-way telehealth visits, when a teaching physician, resident and patient are each in different locations, allow virtual teaching presence.
• 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 was no mention of this provision in the 2026 proposed rule. CMS responded to comments on this topic with a previously published FAQ on how to suppress a practitioner's home address when providing telehealth services, indicating the agency will not be extending this flexibility.

2026 QPP Performance Period

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

• The rule will maintain the performance threshold at 75 points through the 2028 performance period/2030 MIPS payment year.
• CMS finalized a total of 190 quality measures for the 2026 performance period by addressing changes to 30 existing MIPS quality measures, removing 10 quality measures, and adding five quality measures, including two electronic clinical quality measures.
• 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 finalized the addition of six new MVPs for 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 final rule removed 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 final rule requires attestation during MVP registration rather than relying on Medicare claims. The definitions for single specialty groups, multispecialty groups and subgroups were updated to reflect a broader understanding of clinical focus and to align more clearly with MVP reporting structures.
• CMS finalized updates to 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 agency finalized modifications to the Total Per Capita Cost measure candidate event and attribution criteria.
• A two-year informational-only feedback period for new cost measures has been finalized, beginning with the 2026 performance period.
• Minor changes to the Cost, Quality, Improvement Activities and Promoting Interoperability performance categories have been finalized. 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.

Additional information on the final rule can be found in the Medicare PFS Press Release, Fact Sheet, and Addenda, in addition to the MSSP Fact Sheet, QPP Fact Sheet, and MVP Guide. ACC Advocacy staff will provide additional analysis as needed in the weeks ahead. Look for updated information on  ACC.org/Advocacy and in upcoming issues of the ACC Advocate newsletter.

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