Some Ups, Some Downs in Proposed CMS Reimbursement for 2026, Cardiologists Say

Despite an increase in the conversion factor, slashed payments elsewhere could amount to “death by a thousand paper cuts.”

Some Ups, Some Downs in Proposed CMS Reimbursement for 2026, Cardiologists Say

Earlier this month, the US Centers for Medicare & Medicaid Services (CMS) released the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, which increases overall reimbursement for cardiovascular services compared with 2025. While some physician groups worry how the cuts could impact specific procedures, others seem at least somewhat satisfied by the potential for improvements in care delivery.

Clocking in at more than 800 pages, the document proposes to update the conversion factor from $32.34 to $33.58 for qualifying alternative payment model (APM) participants and $33.42 for nonqualifying participants, representing projected increases of about 3.8% and 3.3%, respectively. These changes include the 2.5% temporary increase in reimbursement for physician services for 2026 that was included in the One Big Beautiful Bill Act (OBBA) that passed several weeks ago.

“We’re glad to see the 2.5% in increase that was mandated by the OBBA, but on the flip side, it’s a little bit of ‘death by a thousand paper cuts’ due to the cuts everywhere else,” American College of Cardiology (ACC) President Christopher M. Kramer, MD (University of Virginia School of Medicine, Charlottesville), told TCTMD. “The real increase is going to be very much muted.”

Part of the reason for that is the efficiency adjustment part of the proposed rule, which affects intraservice times and work relative value units (RVUs) for nearly all non-time-based codes and would impose a 2.5% reduction on them.

“So any procedural service is going to be cut by 2.5%,” Kramer added. “Basically, you go up 2.5%, but then you go down 2.5% for those and it’s a wash.”

In a joint statement, the ACC, along with the Society for Cardiovascular Angiography & Interventions (SCAI) and the Heart Rhythm Society (HRS), said they “stand ready to work with the Administration and Congress to address dramatic cuts to high-value procedures such as LAAO [left atrial appendage occlusion], and long-term Medicare payment issues to ensure that seniors maintain access to critical cardiovascular care.”

As part of the proposed rule, reimbursements for LAAO would be cut by 27%, something that the three societies maintain will increase the risk of hospitalization and long-term disability for vulnerable patients.

We’re glad to see the 2.5% in increase that was mandated by the OBBA, but on the flip side, it’s a little bit of ‘death by a thousand paper cuts’ due to the cuts everywhere else. Christopher M. Kramer

Kramer said an important point about these types of proposed cuts is that physicians themselves may bear some responsibility for how their time and work is perceived by policymakers.

“The RUC [Relative Value Update Committee] codes are often based on survey responses,” he noted. “It can be a matter of not enough of our members responding to these surveys [or] when they do, they may not be realistic in terms of [the time it takes] to do procedures, and it just backfires, with inaccurate or not enough responses leading to cuts to that code.”

The ACC, SCAI, and HRS also voiced concern about proposed cuts to some PCI codes. Just last year, the PCI code family was revised and accepted by CMS. The revision included new codes for more complex PCI and for revascularization of chronic total occlusions to more accurately reflect their valuation.

Kramer said the societies are still working through their response to the proposed reimbursement changes as they prepare their official feedback. The public comment period for the PFS proposed rule runs until September 12, 2025.

Another thing the societies are still grappling with, Kramer added, is the ambulatory specialty model for heart failure (HF). Under this alternative pay schedule, CMS would include specialists who treat a set number of HF episodes per year. CMS expects to announce the specialists who are included by the end of this year and begin reimbursing in 2027, with this structure set to run through 2031. Kramer said it’s still unclear what information will be needed in the models to determine how practitioners qualify for inclusion.

“The other area we will need to comment on is the proposed change to payment for indirect practice expense,” Kramer added. “Many or most cardiology practices are hospital employed and integrated rather than independent. CMS is saying that allocation is on the practice expense for hospital-based services [so] the fees there are no longer accurate, and they may reduce it by as much as 50% starting in 2026.”

The American Society of Nuclear Cardiology (ASNC) weighed in on this aspect of the proposed rule, as well, saying this change will result in a dramatic shift of payment between sites of service that may not accurately reflect practice costs.

“CMS chose this methodology over using American Medical Association Physician Practice Information Survey information to update practice relative values,” the ASNC noted in its analysis. The ACC, SCAI, and HRS also note that there are no provisions to update the CMS payment formula for 2026 with information from the survey.

Other Groups Respond

In its statement of response to the proposed rule, the American College of Physicians (ACP) said it is “cautiously optimistic,” while also calling for additional congressional action that they say is needed to protect physician access for Medicare beneficiaries “by strengthening payment for primary care services and preserving access to telehealth.” 

While ACP notes that the proposed rule has “many promising provisions,” one thing they do not support is its attempt to remove coverage of screening for social determinants of health.

“These screenings are crucial for ensuring that a patient’s overall health is accurately represented in their care,” notes ACP President Jason M. Goldman, MD (Coral Springs, FL). “CMS should incentivize care arrangements and services that fully capture all aspects of a patient’s health and enhance the coordination of social services by improving data interoperability and reducing the burden of data collection.”

ATA Action, the advocacy arm of the American Telemedicine Association, say in their statement that the telehealth and digital health provisions in the draft rule “indicate strong commitment” to modernize the healthcare system and integrate technology-enabled services. Among the positives they cite are updates to the Medicare Diabetes Prevention Program (MDPP), expansion of digital mental health treatment codes, and additional payment codes for remote monitoring. Specific to the MDPP is an elimination of the requirements for online-only providers to maintain in-person delivery capabilities and extension of COVID-era telehealth flexibilities. Both of these changes are proposed to remain in effect through 2029.

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