The CY 2026 Medicare Physician Fee Schedule (MPFS) Final Rule, released in late October 2025, represents one of the largest policy updates since the post-pandemic regulatory shift. This rule outlines how Medicare will reimburse providers in 2026, and because Medicare sets the tone for the entire health insurance industry, commercial payers like BCBS, UnitedHealthcare, Aetna, Cigna, & Medicaid MCOs are expected to adopt many of these changes.

This year’s rule focuses on payment stabilization, telehealth modernization, behavioral health expansion, technology-driven care models, & simplification of reporting requirements.

Why CMS Updated the MPFS for 2026

CMS introduced the 2026 Medicare Physician Fee Schedule updates to address shifting practice costs, post-PHE regulatory changes, and the growing need for clearer, more modern reimbursement policies. The goal was to create a more stable framework that aligns with current clinical practices, evolving patient needs, and the rapid expansion of digital care.

• Rising inflation and increased operational costs

• Stabilization following the end of PHE flexibilities

• Expanded access to mental and behavioral health services

• Simplified and more efficient quality reporting

• Clearer rules for telehealth, virtual care, and remote monitoring

• Updated CPT and HCPCS codes to reflect modern care delivery

• Stronger program integrity to prevent misuse, fraud, and inappropriate billing

Key Themes in the 2026 Rule

Here are the largest themes practices will experience in billing and operations:

Conversion Factor Updates for CY 2026

The conversion factor (CF) determines how RVUs translate into actual payment. For the first time in several years, CMS finalized a positive adjustment.

Final CY 2026 Conversion Factor

• Slight increase to help stabilize primary care

• Revalued RVUs for key E/M and behavioral health codes

• Redistribution of funds from high-intensity procedures

Impact by Specialty

Practices should update their 2026 fee schedules before January.

Major Changes to E/M Coding & Reimbursement

CMS continues refining Evaluation & Management rules.

Updated Documentation Requirements for 2026

CMS reinforced:

• Less emphasis on history/physical

• Stronger emphasis on medical decision-making or total time

• Clearer multi-problem visit guidance

• More precise definitions for “stable chronic illness”

Prolonged Services Clarifications

CMS clarified:

• When prolonged codes can be added to E/M

• When telehealth prolonged care is billable

• How shared/split visits determine who gets credit

This helps eliminate misuse or overbilling.

Telehealth Policy for CY 2026

Telehealth remains a major pillar of this year’s final rule.

Permanent Telehealth Codes

CMS permanently approved key services:

• Behavioral health

• Preventive screenings

• Chronic care management check-ins

• Digital therapeutics reviews

• Certain E/M follow-ups

POS & Modifier Rules for 2026

• POS 10 = Home telehealth

• POS 02 = Telehealth outside home

• Modifier 95 remains the required indicator

• Audio-only is allowed only for behavioral health, crisis care, and limited services

RHC/FQHC Telehealth Updates

CMS is expanding:

• Behavioral health via telehealth

• Virtual care management workforce roles

• Updated PPS rates for remote care

Preventive Services & Behavioral Health Changes

Preventive care received substantial enhancements.

New Preventive Coverage Items

CMS added:

• Updated depression screenings

• Youth behavioral screenings

• Cognitive impairment assessments

• Updated cardiovascular prevention tools

Behavioral Health Integration Enhancements

CMS increased payment for:

• Psychiatric collaborative care

• Crisis mental health interventions

• Integrated BH in primary care

• Tele-behavioral health without in-person prerequisites

This supports the growing demand for mental health care access.

Care Management & Chronic Care Coordination Updates

Care management continues to grow as a core Medicare service category.

Updated Care Management Requirements

CMS clarified:

• New time thresholds

• Allowed supervised auxiliary personnel in additional ways

• Simplified documentation for ongoing care plans

RPM & RTM Policy Changes

Remote monitoring rules include:

• Updated device categories

• New code bundles

• Clarified frequency limits

• Increased supervision flexibility

• Clearer reporting of non-face-to-face services

CMS aims to ensure RPM/RTM remains effective while reducing overbilling.

Quality Payment Program (QPP) Changes for MIPS 2026

CMS continues refining the transition from traditional MIPS to MIPS Value Pathways.

New MIPS Value Pathways (MVPs)

CMS added new MVPs targeting:

• Endocrinology

• Pediatrics

• Behavioral Health

• Cardiology

• Pain management

Performance Threshold Updates

CMS raised:

• Scoring benchmarks

• Required reporting elements

• Penalties for low participation

This pushes practices toward higher-quality reporting or opting into an APM pathway.

Stark Law & Split/Shared Updates

Split/Shared Documentation Rule

CMS reinstated clear rules for determining:

• Who performed the substantive portion

• How time or MDM determines billing provider

• When APPs may bill under supervising physicians

Tele-Supervision Rules

CMS extended and expanded tele-supervision for:

• Chronic care

• Virtual digital care

• Behavioral health

• Hospital settings under specific conditions

New CPT & HCPCS Codes for CY 2026

AI & Digital Technology Services

CMS approved:

• New AI diagnostic support review codes

• Digital therapeutic monitoring codes

• Enhanced tele-supervision billing pathways

New Immunization & Diagnostic Codes

CMS expanded:

• Childhood vaccination codes

• Behavioral and substance-use screenings

• Updated infectious disease testing codes

Modifier Policy Changes for 2026

Telehealth Modifiers

• 95 remains primary

• FQ and FR are limited to selected categories

Split/Shared Updates

• New clarifications for who applies the E/M modifiers

• Modified definitions for eligible clinicians

Modifier 25 & 59 Scrutiny

CMS announced tighter audits for:

• Modifier 25 (E/M + procedure same day)

• Modifier 59/X modifiers (distinct procedural services)

Practices should audit these categories regularly.

Compliance, Audit, and Documentation Focus for 2026

CMS will prioritize:

• High-level E/M codes

• RPM/RTM frequency abuse

• Modifier misuse

• Telehealth overbilling

• Incorrect care management reporting

Practices should implement periodic internal audits and staff training to stay ahead.

Commercial Payer Response to CY 2026 Rule

Commercial payers typically mirror Medicare policies within 3–6 months.

Expected Payer Changes

• Updated fee schedules

• New telehealth POS/modifier requirements

• Removal of PHE legacy allowances

• Adoption of select new CPT/HCPCS codes

• Specialty-specific reimbursement updates

BCBS and Aetna usually adopt the majority of CMS policy changes by Q1 2026.

Action Plan: How Your Practice Should Prepare

Here’s a practical checklist:

Practices that prepare early will reduce denials and cash-flow delays in January.

FAQs About the CY 2026 Physician Fee Schedule Final Rule

1. When does the CY 2026 Final Rule go into effect?

January 1, 2026, for all Medicare fee-for-service claims.

2. Are telehealth flexibilities still extended?

Most temporary flexibilities expired, but CMS made several telehealth codes permanent.

3. What are the major winners under the 2026 rule?

Primary care, behavioral health, and telehealth services.

4. Will commercial insurers follow the CMS rule?

Yes, most major payers adopt CMS changes within months.

5. Did CMS change the E/M documentation rules?

Yes, further clarifications were added for prolonged services and multi-problem visits.

6. Are care management services reimbursed at higher rates in 2026?

Yes, new RVUs and code changes increase payments for CCM, RPM, RTM, and BHI.

Conclusion: Preparing for the Largest Billing Changes Since the PHE

The CY 2026 MPFS Final Rule introduces wide-ranging changes that will impact billing, coding, documentation, technology workflows, and payer compliance. Practices that update their workflows early from E/M templates to telehealth POS codes, to new behavioral health and preventive services, will avoid January denials and improve revenue performance throughout 2026.

Contact us today at info@evocarebillings.com or call (323) 412-5399 to explore how we can help your practice grow with smarter, more efficient billing solutions.