2026 MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)
PROPOSED RULE RELEASED
Includes 2026 Quality Payment Program Proposals
Proposed 2026 Conversion Factor:
$33.59 for Qualifying Alternative Payment Model (APM) participants
$33.42 for Nonqualifying APM participants
This afternoon, CMS released the CY 2026 MPFS Proposed Rule. CMS also released a press release, a physician fee schedule fact sheet, and a shared savings program fact sheet. ASCRS will be submitting comments.
2026 MPFS Conversion Factor
As required by MACRA statute, there are two conversion factors for CY26, a conversion factor update of +0.75% for qualifying alternative payment model (APM) participants (QP) and a conversion factor update of +0.25% for nonqualifying APM participants (or those participating in traditional MIPS). Additionally, the One Big Beautiful Bill Act of 2025 includes a 2.5% update for CY26. Therefore, the conversion factor for QPs is $33.59, while the conversion factor for nonqualifying QPs is $33.42.
The CY 2026 proposed MPFS conversion factors of $33.59 and $33.42 represents a 3.83% and 3.62% increase from the CY 2025 MPFS conversion factor (CF) of $32.3465.
CY 2026 proposed MPFS conversion factor reflects the following:
- Mandated updates of 0.75% for APM QPs and 0.25% for nonqualifying participants
- Mandated 2.5% update for CY26 enacted in the One Big Beautiful Bill Act of 2025
- Estimated +0.55% adjustment necessary to account for proposed changes in work RVUs for some services
The proposed Medicare payment rate for 66984 is $466.87, an 11% decrease from the 2025 Medicare payment of $521.75. This is due to reductions in work and practice expense RVUs. Please see the Impact on CY 2026 Payment for Selected Procedures table.
Efficiency Adjustment
CMS states that it has historically relied on the AMA Relative Value Scale Update Committee (AMA RUC) to estimate practitioner time, work intensity, and practice expense, which they state are based on small sample size surveys and a small portion of codes are considered annually. CMS states that research over time has demonstrated that these values are overinflated. Therefore, CMS is proposing to apply a new efficiency adjustment to the work RVU and corresponding intraservice portion of physician time of non-time-based services that CMS expects to accrue gains in efficiency over time. This would periodically apply to all codes except time-based codes, such as evaluation and management (E/M) services, care management services, behavioral health services, services on the Medicare telehealth list, and maternity codes with a global period of MMM.
For CY26, CMS is proposing to use a sum of the past five years of the Medicare Economic Index (MEI) productivity adjustment percentage to calculate this new efficiency adjustment. The agency is proposing a look-back period of five years, which would result in a proposed efficiency adjustment of -2.5% for CY 2026. As a result, the proposed efficiency adjustment for the work RVU for 66984 decreased from 7.35 to 7.17.
Practice Expense
CMS primarily relies on the AMA’s Physician Practice Information (PPI) Survey data from 2008 that measures specialty-specific practice costs to determine practice expense. In 2024, the AMA conducted an updated survey for CMS consideration for the CY26 MPFS. However, due to limitations with the survey data, CMS is proposing not to use the updated survey data. Rather, CMS is proposing to recognize greater indirect costs for practitioners in office-based settings compared to facility settings. However, due to the decline in physicians working in private practice, CMS believes indirect costs for PE RVUs in the facility setting at the same rate as the non-facility setting does not reflect current clinical practice.
CMS is proposing to utilize data from auditable, routinely updated hospital data (i.e., from the Medicare Outpatient Prospective Payment System (OPPS)) to set relative rates and inform cost assumptions for some technical services paid under PFS. For CY26, the practice expense for 66984 decreased from 8.23 to 6.16. Additionally, Addendum B includes non-facility practice expense RVUs for cataract and other ophthalmic procedures although there is no specific mention of this change in the rule.
Medicare Telehealth Services
For CY 2026, CMS is proposing to simplify the review process for including telehealth services by removing the distinction of provisional and permanent services to the Medicare Telehealth Services List. CMS is proposing to limit their review to whether the service can be furnished using an interactive, two-way audio-video telecommunications system.
Direct Supervision
CMS is proposing to permanently adopt a definition of direct supervision that allows the physician or supervising practitioner to provide such supervision through real-time audio and visual interactive telecommunications (excluding audio-only). CMS is proposing to exclude 10- and 90-day global services from virtual direct supervision of applicable incident-to services.
Teaching Physicians
CMS is proposing not to extend current policy to allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings. Instead, CMS is proposing to revert back to the pre-public health emergency policy which requires that, for services provided within MSAs, teaching physicians must maintain physical presence during critical portions of resident-furnished services to qualify for Medicare payment. CMS would maintain the rural exception established in the CY 2021 PFS final rule metropolitan statistical area.
Improving Global Surgery Payment Accuracy
In their ongoing review of global surgery payments, CMS is requesting comment on the next steps to improve accuracy and payment of global surgery payments. Specifically, CMS is requesting comments on procedure shares and what the procedure shares should be based on when the transfer of care modifier(s) are applied for the 90-day global packages and division of work between a surgeon and providers of post-operative care.
Quality Payment Program
MIPS Value Pathways (MVPs)
CMS is proposing minor modifications to the Complete Ophthalmologic Care MVP. These changes reflect measure proposals made under traditional MIPS.
For multispecialty groups reporting via MVPs, CMS previously finalized that they must create multiple MVP subgroups as mandatory beginning in 2026. In this proposed rule, CMS is proposing to modify the definition and determination of a multispecialty group. Rather than being based on a two-digit specialty code, CMS is proposing to have groups self-report their specialty mix during MVP registration. Specifically, groups would report that they are single specialty if they consist of only one specialty type or of clinicians involved in a single focus of care. This means that ophthalmic groups with optometrists or non-physician advanced care practitioners would no longer be considered multi-specialty. In addition, CMS is proposing to exempt small practices from the subgroup requirement.
Finally, CMS reaffirmed its intention to sunset traditional MIPS and move to mandatory MVPs in the future. There is no proposal, however, CMS has previously introduced a potential timeline that identifies the 2029 performance year as a potential for sunsetting MIPS. ASCRS maintains that the traditional MIPS pathway should continue to be an option.
Performance Threshold Proposals
CMS is proposing to keep the performance threshold at 75 points for the 2026–2028 performance years to provide continuity and stability to MIPS clinicians.
Performance Category Weights
For the 2026 performance year/2028 payment year, the performance category weights are the following:
- 30% for the Quality performance category.
- 30% for the Cost performance category.
- 15% for the Improvement Activities performance category.
- 25% for the Promoting Interoperability performance category.
Quality
CMS will maintain a data completeness threshold of 75% for 2027 and 2028 performance periods.
Defined Topped Out Measure Benchmarks
CMS is proposing that 19 quality measures receive the previously defined topped out measure benchmarks for the CY 2026 performance period. These measures belong to specialty sets and MVPs with limited measure choice and a high proportion of topped out measures, which prevents meaningful participation in MIPS.
One of the measures proposed to be included is Quality ID 141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care (Medicare Part B Claims collection type only).
Relevant Measures Proposed for Removal in 2026:
- 419: Overuse of Imaging for the Evaluation of Primary Headache
- Rationale for Proposed Removal: Extremely topped out
- 487: Screening for Social Drivers of Health
- Rationale for Proposed Removal: Removal of a process measure that would no longer be considered a high-priority measure and aligns with removal across other CMS programs
- 508: Adult COVID-19 Vaccination Status
- Removal of a process measure that aligns with removal across other CMS programs.
Cost
There are no proposed new MIPS Cost measures for performance year 2026.
In a huge success for our advocacy efforts, CMS is proposing to change the attribution methodology for the Total Per Capita Cost (TPCC) measure. Currently, all services billed by advanced practice nonphysician practitioners (NPs, PAs, and CCNSs) are classified as primary care under the TPCC. Because of this, ophthalmic groups employing NPs or PAs have been inappropriately attributed the TPCC measure, despite ophthalmologists and optometrists being excluded from the measure. CMS is proposing to fix this issue by excluding NPs/PAs/CCNSs from the TPCC if they are part of a clinician group where all other clinicians are excluded based on specialty.
We saw a second major win in the Cost category. CMS is proposing changes to how they introduce new MIPS cost measures. Specifically, CMS proposes to implement new cost measures on an information-only basis (not counted toward the MIPS Cost score) for two years. This will allow us to gain insight into how measures are attributed and scored and provide an opportunity to test any changes made based on any issues encountered in the first year.
Promoting Interoperability
CMS is proposing several significant changes to the MIPS Promoting Interoperability (PI) category. The following changes would begin in performance year 2026, unless otherwise specified:
- For 2025 MIPS: CMS is proposing to suppress (not score) the Electronic Case Reporting measure because of the temporary pause in onboard enacted by the CDC.
- Security Risk Analysis (SRA) measure: CMS proposes to add a second attestation statement to this measure. This would require clinicians to attest “Yes” to both of the following: (1) Completing an SRA, and (2) Implementing security measures to address the vulnerabilities found. This is already required under HIPAA.
- SAFER Guide attestation: CMS proposes to require the use of the new 2025 SAFER Guides beginning in 2026.
- PI Bonus measures: CMS proposes adding a new option, “Public Health Reporting Using TEFCA.” This would require clinicians to attest to being in active engagement option 2 (validated data production) with a public health agency to transfer health information using TEFCA.
- Query of PDMP measure: Although no proposals have been made for this measure, CMS is seeking feedback on whether they should change the measure from an attestation-based measure (“Yes” or “No”) to a performance-based measure (numerator and denominator). CMS is also seeking feedback on expanding the types of drugs included in the Query of PDMP measure.
Improvement Activities
CMS is proposing to remove 8 improvement activities for the 2026 performance year. These are the same activities that were suspended for 2025:
- IA_ AHE_5: MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
- IA_AHE_8: Create and Implement an Anti-Racism Plan
- IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
- IA_AHE_11: Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients
- IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
- IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
- IA_PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities
- IA_ERP_3: COVID-19 Clinical Data Reporting with or without Clinical Trial
CMS is also proposing to remove the Achieving Health Equity subcategory altogether and replacing it with a new Advancing Health and Wellness subcategory.
As a reminder, there are also improvement activities that were previously finalized for removal in 2026, which include IA_CC_1 (Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop) and IA_CC_2 (Implementation of Improvements that Contribute to More Timely Communication of Test Results).
A fact sheet is available on the CY 2026 Quality Payment Program proposed changes.
Additional Details to Come
ASCRS is reviewing the 1,803-page proposed rule, and additional information will be detailed in upcoming editions of Washington Watch Weekly.
