Advocacy & Practice Updates — Advocacy & Practice
New Payment Proposals for the 2026 Medicare Program
On July 14, CMS released its 2026 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B (CMS-1832). This proposed rule revises payment policies under the Medicare physician fee schedule and makes other policy changes to payment under Medicare Part B beginning January 1, 2026. Additionally, this rule proposes other updates to the Quality Payment Program.
Two Conversion Factors for 2026
For the first time in 2026, the MACRA law requires that Medicare must implement two separate conversion factors dependent on participation in advanced alternative payment models (A-APMs). For those who participated in an A-APM, the increase would be 0.75%. All other clinicians will receive a 0.25% update. In addition, Congress separately enacted on July 3, a one-year 2.5% increase to the 2026 conversion factor set by law.
Including this one-year increase, CMS is proposing to set the 2026 qualifying APM conversion factor of $33.59, representing a projected increase of $1.24 (+3.83%) from the current conversion factor of $32.35. The proposed CY 2026 nonqualifying APM conversion factor is $33.42 representing a projected increase of $1.17 (+3.62%) from the current conversion factor of $32.35.
Practice Expense Methodology and the Medicare Economic Index
After several years of attempting to measure the practice expense costs, CMS is electing to significantly update its PE methodology to reflect medical practice that is delivered in facility settings. CMS has decided against using data from the AMA PPI and CPI surveys but rather will use indirect cost data for PE RVUs from the Medicare Outpatient Payment System (OPPS). This will be used for developing the value of the MEI, the main measure of inflation in Medicare.
CMS Proposes New Efficiency Adjustment
CMS is proposing to move away from the AMA RUC survey process and instead is planning to use an efficiency adjustment to mitigate what it considers overinflated relative valuations of services. This adjustment of -2.5% for 2026 essentially wipes out the increase in the proposed conversion factor. ASRS and the medical community will strenuously push back on this proposal.
New and Revised CPT 2024 Coding Changes
Dark Adaptation Diagnosis Screening and Services
A review of dark adaptation CPT code 92284 was initiated due to an increase in the Medicare claims volume. CPT Code 92284 was re-surveyed with a new code 922X1 (created to describe the diagnostic screening portion of the code). The RUC recommended a value of 0.32 for CPT Code 92284 and a value of 0.17 for CPT Code 922X1. CMS accepted the practice expense inputs for Code 92284. CMS, however, did not accept the proposed RUC work value, instead CMS recommends a work value of 0.29 for CPT Code 92284. For CPT Code 922X1 CMS proposes to assign status (“N”) to indicate a non-covered service under Medicare.
Global Surgery Payment Accuracy
CMS included a new request for information related to payment for 10- and 90-day global surgery codes in this proposed rule. They are asking what additional steps should be taken to assure the accuracy of these codes and specifically how payment should be allocated between different practitioners when a provider other than the surgeon furnishes post-op care. ASRS will continue to urge CMS to base values on recommendations from the physician-driven AMA Relative Value Update Committee (RUC).
Quality Payment Program
CMS is once again proposing to set the 2026 MIPS performance threshold at 75 points, no change from the current 2025 level. MIPS participants whose final score is above the threshold are eligible for positive payment adjustments in 2028, while those falling below will be subject to a penalty. MIPS category weights for 2026 are proposed to remain at current levels of 30% Quality, 30% Cost, 25% Promoting Interoperability and 15% Improvement Activities. Most retina specialists will continue to have no applicable cost measures and have the weight of that category re-assigned to Quality.
CMS is proposing to remove retina quality measures that relate to health equity from the Ophthalmology measure set and the Complete Ophthalmologic MIPS Value Pathway (MVP). These two measures are 487 Social Drivers of Health and 498 Connection to Community Service Providers.
Medicare Value Pathways (MVPs)
CMS also requests information on strategies to increase physician participation in this MIPS reporting method.
ASRS will continue to analyze this rule and provide updates in the coming days. The CMS Medicare Physician Fee Schedule Fact Sheet is found here. The CMS press release is found here. The CMS Quality Fact Sheet is found here. For additional information, visit the ASRS website. If you have questions, please contact Allison Madson, vice president of Health Policy, at allison.madson@asrs.org.
?(Published 7.15.25)