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CY 2026 Medicare Physician Fee Schedule and Quality Payment Program Final Rule

On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS) released its Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) final rule and associated fact sheet. This update provides an overview of the policy and payment changes most impactful to electrophysiology services. The finalized changes will take effect on January 1, 2026, unless otherwise noted.

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Beginning in CY 2026, the PFS conversion factor (CF) will vary based on whether clinicians participate in an Advanced Alternative Payment Model (APM). Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), clinicians who qualify as Advanced APM participants will receive a 0.75% base payment update for the services they provide, while services delivered by all other clinicians will receive a 0.25% update. As a result, CMS finalized the following two CFs for CY 2026:

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  • $33.5675 for items and services furnished by Qualifying Participants (QPs) in an Advanced APM, which reflects a 3.77% increase relative to the 2025 CF

  • $33.4009 for items and services furnished by all other providers, which reflects a 3.26% increase relative to the 2025 CF

 

While the proposed rule includes a modest across-the-board increase to the CFs, the actual impact on payments vary widely by specialty and is largely offset by broader policy changes that substantially reduce reimbursement for some electrophysiology services, as discussed below.

Key Payment Policy Changes

  • Reduction in Work RVUs through “Efficiency Adjustment.” CMS finalized a new “efficiency adjustment” to work relative value units (RVUs) based on its belief that many procedural codes are not revalued frequently enough to reflect anticipated efficiency gains over time. As a result, CMS implemented a uniform 2.5% reduction to work RVUs for non-time-based services, which includes codes for most procedures. This affects not just Medicare payments but could also impact electrophysiologists with RVU-based employed contracts. CMS also finalized a policy to make this adjustment every three years based on the productivity adjustment calculated as part of the Medicare Economic Index (MEI).

    Payment for physician services performed in facilities will decrease overall by 7% while payment for physician services performed in non-facility settings will increase by 4% according to CMS impact files. While the impact will vary by specialty, many specialists who see patients in hospitals settings and ambulatory surgery centers, such as electrophysiologists, will face cuts. On the other hand, specialists who primarily see patients in an office, such as primary care providers, will see a pay increase.

 

  • Reallocation of Practice Expenses. CMS also finalized major changes to how it calculates indirect practice expense (PE) RVUs. Based on its belief that current methodology overestimates the PE costs associated with services performed in facility settings, CMS finalized the policy shifting PE RVUs away from facility-based services towards office-based care. In practical terms, this executes a substantial redistribution of Medicare dollars that favors office-based practices at the expense of clinicians who primarily practice in hospitals and ambulatory surgery centers.

    The Society expressed strong opposition to implementation of the efficiency adjustment and PE site of service differential in its comment letter on the proposed rule stating that the CMS methodologies are flawed and risks undermining patient access to essential electrophysiology procedures.  Heart Rhythm Advocates is working with other medical societies to prevent implementation of the efficiency adjustment before January 1, 2026, and recently urged Society members to contact their state Senators and Representatives to intervene.

Combined Impact on Select EP Services

​Together, these changes significantly impact electrophysiology reimbursement, particularly for facility-based practitioners. For example:

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  • Left atrial appendage closure (CPT 33340) will see its work RVUs reduced in CY2026.  CMS accepted the RUC-recommended work RVU of 10.25 following a flawed survey, reflecting a 27% reduction from the current work RVU of 14.00.  Although the code was revalued for CY 2026 and experienced a substantial reduction in work RVUs, CMS exacerbated the reduction by applying the -2.5% efficiency adjustment, further reducing the work RVU to 9.99%, reflecting a 29% cut.  The efficiency adjustment compounded with the PE changes will decrease total physician payment for left atrial appendage closure by 33% in CY 2026 compared to CY 2025, even with the increases to the CF. However, due to statutory limits on how much RVUs can decline in a single year, CMS is required to phase in this reduction over two years. As a result, physician payments for CPT 33340 will decrease by 16.38% in CY 2026, with the remainder of the cut taking effect in CY 2027.  HRS, ACC and SCAI are resurveying CPT code 33340 for the January 2026 RUC meeting.  The new values, if approved by CMS, will be implemented January 1, 2027.
     

  • On the bright side of the ledger, the Society is excited to announce that CMS accepted comments recommending updates to the PE inputs for intracardiac catheter ablation for atrial fibrillation (CPT code 93656). While the work RVUs for CPT 93656 were cut by 2.47%, now that the PE inputs have been corrected, total payment for CPT 93656 will increase by over 63%.
     

  • CMS accepted RUC-recommended work RVUs for seven of eight new baroreflex activation therapy services (CPT codes 64654, 64655, 64656, 64657, 64658, 64659, 93145, and 93146) to treat patients with heart failure.  CMS did not accept the RUC-recommended work RVU for programming CPT code 93145 and instead reduce the value from 0.79 to 0.65 as proposed based on a crosswalk to a similar code. However, CMS changed its decision and accepted the RUCs recommendations to use the higher level registered nurse (RN) clinical staff (L051A) for device interrogation and programming codes 93145 and 93146, instead of the lower level blended clinical staff (L037D) as proposed. Because these are new codes for CY 2026, they are exempt from the efficiency adjustment. 
     

  • CMS For CY 2026, will streamline the process for adding services to the Medicare Telehealth Services List by simplifying the review process by removing the distinction between provisional and permanent services and limiting the review on whether the service can be furnished using an interactive, two-way audio-video telecommunications system. CMS also permanently removed frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations.  For services that are required to be performed under the direct supervision of a physician or other supervising practitioner, CMS permanently adopted 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). Except for services that have a global surgery indicator of 010 or 090, physician or other supervising practitioner may provide such virtual direct supervision for applicable incident-to services for diagnostic tests, pulmonary/cardiac rehabilitation services and intensive cardiac rehabilitation services. 
     

  • CMS updated the total RVU for remote monitoring technical component CPT code 93296 from 0.60 to 0.95 resulting in an approximate 60% increase in payment effective 2026. CMS agreed that the technician for this code should be a cardiovascular technician (L038B) rather than an electrodiagnostic technician (L037A), and the current equipment code (EQ320) should be updated (to EQ198). 

Ambulatory Specialty Model (ASM)

Concerningly, CMS finalized a new mandatory Innovation Center model, the Ambulatory Specialty Model (ASM), which is set to begin in CY 2027. This model will require participation from specialists in designated regions and will target chronic conditions related to heart failure and low back pain.  The model is based on the flawed structure of the Merit-Based Incentive Payment System (MIPS), linking future Medicare Part B payments to provider performance across four MIPS-like categories without the flexibility to choose measures and activities most relevant to one’s practice.  Participants would also be subject to higher risk than under MIPS, facing a maximum payment penalty of up to 12% of Medicare Part B payments based on performance in future years. 

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For the heart failure cohort in the model, eligible participants include clinicians who have been assigned a specialty code of cardiology based on the plurality of their Medicare Part B claims. HRS is pleased that CMS finalized its proposal to exclude clinicians with a cardiac electrophysiology or other cardiac specialty designation from the model as the Agency does not believe proceduralists play a primary role in the ongoing, longitudinal care of heart failure patients or maintain regular interactions with primary care providers. However, CMS has noted it could broaden the pool of participants in the future if it is determined that patterns of care exhibited by other subspecialty types make for fair comparison on the same set of measures.

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HRS will keep a close eye on developments and findings related to this model given CMS’s interest in potentially expanding this problematic model to other specialties and conditions over the longer term. 

Key Changes Facing Qualifying Participants in Advanced APM

Advanced Alternative Payment Models (APMs) are a track within the Quality Payment Program (QPP) that offer incentives to eligible clinicians who meet specific participation thresholds based on their Medicare Part B payments or patient counts through an Advanced APM. Clinicians who meet these thresholds are designated as Qualifying APM Participants (QPs).

To qualify as an Advanced APM, a model must meet the following criteria:
 

  • Use of Certified EHR Technology (CEHRT);

  • Payment based on quality measures comparable to those used in the MIPS Quality performance category;

  • Assume significant financial risk, or be a Medical Home Model expanded under the CMS Innovation Center.
     

Note that the Ambulatory Specialty Model described above is not considered an Advanced APM at this time. 

QP status is determined based on performance during a year that occurs two years prior to the payment year. For example, to qualify for QP status for the 2026 payment year, clinicians needed to meet one of the following thresholds during the 2024 performance period:
 

  • Receive at least 50% of their Medicare Part B payments through an Advanced APM Entity, or

  • See at least 35% of their Medicare patients through an Advanced APM Entity.
     

Starting with the 2025 performance period (which impacts the 2027 payment year), these thresholds increased to 75% of Medicare Part B payments or 50% of Medicare patients. In addition to these thresholds, eligible clinicians must also meet other requirements, such as the use of CEHRT.  Although the CY 2026 PFS final rule included some refinements to the QP determination methodology that are intended to help specialists meet the QP criteria starting with the 2026 performance year, the increasing QP thresholds, which are required under statute and outside of CMS’s control, will likely offset any potential gains associated with these new policies. 

 

As noted above, beginning in CY 2026 payment year, QPs are eligible for a higher PFS update than non-QPs (For CY 2026, a conversion factor of $33.5675).  Additionally, QPs are exempt from reporting under MIPS. However, the limited availability of specialty-focused Advanced APMs, tied with the increasing eligibility thresholds, will likely result in few electrophysiologists qualifying for the QP conversion factor.

 

To check if you qualify as a QP, visit the QPP Participation Status Tool and enter your National Provider Identifier (NPI).

Additional information on Advanced APMs and QP Status is available on the CMS QPP Website.

CY 2026 Medicare Physician Fee Schedule Proposed Rule Takeaways

On July 14, 2025, the Centers for Medicare & Medicaid Services (CMS) released the proposed Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2026, which includes proposals related to Medicare physician payments and the Quality Payment Program (QPP). 

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Beginning in CY 2026, the MPFS conversion factor (CF) will, for the first time, vary based on a clinician’s participation in an Advanced Alternative Payment Model (APM). Under MACRA (Medicare Access and CHIP Reauthorization Act), clinicians who qualify as Advanced APM participants will receive a 0.75% base payment update for the services they provide, while services delivered by all other clinicians will receive a 0.25% update. (See below for additional information about Advanced APM status.)

 

As a result, CMS proposes the following two CFs for CY 2026:

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  • $33.5875 for items and services furnished by Qualifying Participants (QPs) in an Advanced APM, which reflects a 3.84% increase relative to the 2025 CF (See below for additional information on Advanced APMs) 

  • $33.4209 for items and services furnished by all other providers, which reflects a 3.32% increase relative to the 2025 CF

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While the proposed rule includes a modest across-the-board increase to the CF, the actual impact on payments varies widely by specialty and is largely offset by broader policy changes that could substantially reduce reimbursement for electrophysiology services, as discussed below.

Key Proposed Payment Changes

  • Reduction in Work RVUs through “Efficiency Adjustment.” CMS is proposing a new “efficiency adjustment” to work relative value units (RVUs) based on its belief that many procedural codes are not revalued frequently enough to reflect anticipated efficiency gains over time. As a result, CMS proposes a uniform 2.5% reduction to work RVUs for non-time-based services, which includes codes for most procedures. CMS proposes to make this adjustment every three years based on the productivity adjustment calculated as part of the Medicare Economic Index (MEI).

  • Reallocation of Practice Expenses. CMS is also proposing major changes to how it calculates indirect practice expense (PE) RVUs. Based on analyses from MedPAC, CMS believes that current methodology may overestimate the PE costs associated with services performed in facility settings. The proposed change would shift PE RVUs away from facility-based services towards office-based care. In practical terms, this would mean a substantial redistribution of Medicare dollars that favors office-based practices at the expense of clinicians who primarily practice in hospitals or other facilities. 

Combined Impact on EP Services

​Together, these two proposed changes would significantly impact electrophysiology reimbursement, particularly for facility-based practitioners. For example:

  • Left Atrial Appendage Closure (CPT code 33340) would see its work RVUs reduced from 14.00 in CY 2025 to 9.99 in CY 2026, or a nearly 29% cut. This reflects proposed changes that CMS is making to this code to accept the RUC-recommended work RVU of 10.25 for CPT 33340 and then applying the “Efficiency Adjustment” on top of that.

  • When combined with the proposed PE changes, total physician payments for CPT code 33340 would fall by 32.6% in CY 2026 compared to CY 2025, even with the increases to the conversion factor. However, due to statutory limits on how much RVUs can decline in a single year, CMS would phase in this reduction over two years. As a result, facility-based physician payments for CPT code 33340 would decrease by 16.3% in CY 2026, with the remainder of the cut taking effect in CY 2027.

  • In another example of CMS’ arbitrary cuts, even though no other changes were proposed specifically for AFib ablation (CPT code 93656), the major methodological changes that CMS is proposing for work and practice expense throughout the fee schedule would decrease the work RVUs for CPT code 93656 by 2.47% and drastically cut overall Medicare payment by more than 9%.

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HRS and HRA strongly oppose these proposals. We believe the CMS methodology is flawed and risks undermining patient access to essential electrophysiology procedures. HRS and HRA are working closely with other medical organizations to push back against the proposed cuts and advocate for fair reimbursement.

Public comments on the proposed rule are due by September 12, 2025 and may be submitted at regulations.gov.

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Ambulatory Specialty Model (ASM)

As part of the MPFS proposed rule, CMS proposes a new mandatory Innovation Center model, the Ambulatory Specialty Model (ASM), which is set to begin in CY 2027. This model would require participation from specialists in designated regions and will target chronic conditions related to heart failure and low back pain. Based on the structure of the Merit-Based Incentive Payment System (MIPS), the ASM will link future Medicare Part B payments to provider performance across four MIPS-like categories and clinicians could be eligible for positive, neutral, or negative payment adjustments. Depending on the model year, clinicians could face maximum payment penalties ranging from 9% to 12% based on performance under the model.

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For the heart failure cohort in the model, CMS plans to include clinicians who have been assigned a specialty code of cardiology based on the plurality of their Medicare Part B claims. In the rule, clinicians with a cardiac electrophysiology or other cardiac specialty designation are excluded from the model because it does not believe proceduralists play a primary role in the ongoing, longitudinal care of heart failure patients or maintain regular interactions with primary care providers. That said, CMS is requesting public comment on the potential inclusion of other cardiology specialty codes. Preliminary participant selection is expected by the end of 2025.

 

While HRS and HRA are still evaluating the proposed model, we are concerned that the model could increase reporting burden, particularly for clinicians who have traditionally reported MIPS through a group or an APM. There is also concern that some clinicians may face even larger payment penalties under the ASM as compared to MIPS.

What is an Advanced APM?

Advanced Alternative Payment Models (APMs) are a track within the Quality Payment Program (QPP) that offer incentives to eligible clinicians who meet specific participation thresholds based on their Medicare Part B payments or patient counts through an Advanced APM. Clinicians who meet these thresholds are designated as Qualifying APM Participants (QPs).

 

To qualify as an Advanced APM, a model must meet the following criteria:

  • Use of Certified EHR Technology (CEHRT);

  • Payment based on quality measures comparable to those used in the MIPS Quality performance category;

  • Assume significant financial risk, or be a Medical Home Model expanded under the CMS Innovation Center.

 

QP status is determined based on performance during a year that occurs two years prior to the payment year. For example, to qualify for QP status for the 2026 payment year, clinicians needed to meet one of the following thresholds during the 2024 performance period:

  • Receive at least 50% of their Medicare Part B payments through an Advanced APM Entity, or

  • See at least 35% of their Medicare patients through an Advanced APM Entity.

 

Starting with the 2025 performance period (which impacts the 2027 payment year), these thresholds increased to 75% of Medicare Part B payments or 50% of Medicare patients. In addition to these thresholds, eligible clinicians must also meet other requirements, such as the use of CEHRT.

 

As noted above, beginning in CY 2026 payment year, QPs are eligible for a higher PFS update than non-QPs (For CY 2026, a conversion factor of $33.5875). Additionally, QPs are exempt from reporting under MIPS. However, the limited availability of Advanced APMs for specialists has been on ongoing issue and will likely result in few electrophysiologists qualifying for the QP conversion factor.

 

To check if you qualify as a QP, visit the QPP Participation Status Tool and enter your National Provider Identifier (NPI). 

 

Additional information on Advanced APMs and QP Status is available on the CMS QPP Website.

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HRS/HRA Comment Letter

On September 12, 2025, the Heart Rhythm Society (HRS) and Heart Rhythm Advocates (HRA) recently submitted our comment letter with our position on the proposed rule. Read the full comment letter.

 

In summary, we respectfully requested that CMS:

  • Reject the RUC-recommended work RVU of 10.25 for Closure Left Atrial Appendage with Endocardial Implant (CPT code 33340), and instead maintain the current work RVU of 14.00 until the code can be properly resurveyed for the January 2026 RUC meeting with the PCI and LER codes on the RSL.

  • Exempt 33340 and cardiac catheter ablation codes (93653 – 93657) from the proposed efficiency adjustment and PE policy that have already been revalued by the RUC over the last five years, and reduced to account for increased efficiency.

  • Accept the RUC recommended work RVU of 0.79 for Baroreflex Activation Therapy code 93XX4 and clinical labor (L051A) time for 93XX4 and 93XX5, given the difference in skill, responsibility, and clinical risk.

  • Withdraw the proposed efficiency adjustment or adopt an exclusion to the policy for new codes and codes that have been revalued within the previous five years.

  • Withdraw the proposed PE methodology or apply it in a more narrowly-tailored approach so it does not inadvertently apply the payment cuts to physician services that are not the object of CMS’ criticism.

  • Finalize updates to technology and technician inputs for CPT 93296 in the CY 2026 rule and collaborate with specialty societies on future reassessment of time values once independent validation is available.

  • Work with Congress to ensure that the flexibilities of general Medicare telehealth are permanently extended beyond the September 30, 2025 deadline.

  • Not require mandatory participation in MVPs until CMS first addresses several fundamental issues within both MIPS and the MVP framework.

  • Not proceed with implementation of the proposed ASM model, and instead collaborate with specialty societies to address the persistent lack of specialty-focused APMs, develop and test specialty-focused Advanced APMs, and allow specialists to self-attest to their subspecialty to determine ASM eligibility.

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