Navigating the 2026 Medicare Physician Fee Schedule Proposed Rule: What Changed and What to Do Now

2026 Medicare PFS Proposed Rule: Conversion Factors, MIPS, and APMs

For 2026, CMS proposes two conversion factors and modest payment increases tied to APM participation, reversing prior across‑the‑board cuts and signaling a stability-first approach for MIPS and QPP participation paths.

What’s new for 2026

CMS proposes separate conversion factors for qualifying APM participants (QPs) and non‑QPs, with both rising versus 2025: QP CF to about $33.59 (+3.8%) and non‑QP CF to about $33.42 (+3.3%), reflecting statutory updates and a one‑year 2.5% increase baked into 2026. CMS emphasizes limited structural change across the Quality Payment Program for stability, while continuing the long‑term shift toward MVPs and digital quality measurement.

Key dates and commenting

The CY 2026 PFS proposed rule was released mid‑July 2025, with comments due in early September via the Federal Register and CMS’s Physician Fee Schedule hub; finalization typically occurs in November for January 1 effective dates. CMS’s PFS page provides the docket details, instructions, and links to the fact sheet and addenda for code‑level impacts.

Conversion factors and rate dynamics

Beginning in 2026, statute requires two CFs: QPs receive the QP CF with a +0.75% statutory update, and non‑QPs receive the non‑QP CF with a +0.25% update, with both incorporating a one‑year +2.5% increase and adjustments for work RVU proposals and budget neutrality. The proposed CFs—$33.59 (QP) and $33.42 (non‑QP)—represent increases from the 2025 baseline of $32.35 and mark a policy pivot from prior years’ reductions.

Specialty and site‑of‑service implications

CMS proposes changes that may shift dollars between facility and non‑facility settings, with stakeholder analyses noting possible pressure on facility‑based services and relative gains in non‑facility contexts, varying by specialty mix and service location. Several summaries project roughly neutral to slightly positive overall impacts for some specialties, with cardiology analyses, for example, estimating divergent effects between facility (down) and non‑facility (up) service profiles depending on case mix.

E/M and high‑volume procedures

CMS’s 2026 proposals do not overhaul office E/M structure, and the conversion factor increases apply uniformly; however, code‑level RVU refinements can still move payments at the service level, so practices should model top CPT codes using CMS addenda. Stakeholder summaries highlight continued relativity adjustments to balance cognitive and procedural services, making RVU review essential for high‑volume procedures.

Telehealth and virtual care updates

The 2026 PFS continues the trend of integrating telehealth into routine physician payment with targeted refinements, with societies noting expansions of certain services and continued alignment with Part B policies; practices should confirm code lists, place of service, and modifier rules as finalized. CMS maintains its broader QPP push toward digital measures, which complements telehealth documentation and eCQM reporting strategies.

MIPS and QPP: stability with signals

CMS proposes keeping the MIPS performance threshold at 75 points, retaining category weights, and applying topped‑out scoring rules to selected measures, keeping program expectations steady for 2026 while advancing MVP availability. CMS reiterates that MVPs remain optional in 2026 but will expand, with signals that a fuller transition could arrive later in the decade, alongside continued emphasis on eCQMs as the preferred standard.

APM participation advantages

Qualifying APM participation remains financially meaningful through the distinct QP conversion factor and savings opportunities within advanced models, subject to threshold criteria and ongoing model updates. CMS’s fact sheet quantifies the QP CF advantage vs non‑QP and outlines the statutory basis for the split, supporting strategic evaluation of ACO and other APM options for eligible groups.

What to do now

• Run impact modeling: Use CMS Addendum B and the PFS lookup to model 2026 revenue for top CPTs under both QP and non‑QP CF scenarios and across facility vs non‑facility sites.
• Tune the service mix: Evaluate marginal RVU changes and consider shifting capacity toward cognitive services and non‑facility encounters if local payer dynamics align with CMS’s proposed relativity and site signals.
• Lock in MIPS ≥75: Confirm 2026 measure sets, data completeness, and topped‑out items; pursue MVP options if they better match the specialty and data infrastructure.
• Advance APM strategy: Assess eligibility and alignment with advanced APMs, including ACO models, to capture the QP CF and shared savings potential where feasible.
• Strengthen digital reporting: Prioritize eCQM readiness and interoperability, as CMS continues the digital quality roadmap and stability stance through 2026.

Compliance and preparation checklist

• Update fee schedules and payer contracts using the proposed CFs and code‑level RVU changes; revisit parity clauses and site‑of‑service terms ahead of 2026.
• Validate telehealth coding: Confirm codes, modifiers, and documentation workflows that align with 2026 proposals and prepare to adjust at final rule.
• Monitor finalization: Track CMS’s PFS page and QPP site for final rule updates, measure lists, and submission mechanics before year‑end.

In short, the 2026 PFS is a signal to plan, not panic—conversion factor updates, steady MIPS expectations, and clearer APM advantages create room to protect margins if action starts now. Prioritize code‑level impact modeling, reinforce documentation and digital reporting, and align service mix and contracts to proposed relativity and site‑of‑service shifts. Practices that lock in a ≥75 MIPS score, validate telehealth workflows, and evaluate APM pathways will be best positioned to offset pressure and capture upside when the final rule takes effect on January 1, 2026.

Learn More…