Physician Payment Proposal is a Mixed Bag for GI
On July 14, the Centers for Medicare and Medicaid Services (CMS) released proposed payment rates for physician services for calendar year (CY) 2026.
Here are the top takeaways:
- Payment increases for office-based services, cuts for ASC/hospital-based services: Using new methodologies that CMS believes will benefit private practices, CMS is proposing changes to how physician practice expenses are calculated for office-based versus facility-based services. This is resulting in significant payment changes based on site of service.
- Conversion factor increase: The “One Big, Beautiful Bill” that Congress passed on July 3 will increase the CY 2026 conversion factor to $33.42 for most physicians, a projected increase of $1.17, or 3.62%, from the current conversion factor of $32.35.
- New “efficiency adjustment” cuts RVUs for GI procedures: CMS proposes an “efficiency adjustment,” of –2.5% applied to work RVUs and procedure time at the code level because CMS believes clinicians become more efficient over time in performing procedures. “Efficiency” cuts would be applied every three years.
- Direct supervision via telehealth will continue: CMS proposes to make permanent that physicians may provide direct supervision remotely for procedures, except 010- and 090-day global codes.
Key CY 2025 HOPD/ASC takeaways for GI:
- 2.4% payment increase for ASCs and hospital outpatient departments for those meeting quality reporting requirements.
- Adding more than 500 procedures that can be performed in ASCs, including GI code POEM (CPT 43497). CMS also proposes relaxing criteria for adding procedures to the ASC Covered Procedures List (ASC CPL), which could open the door for the inclusion of more GI procedures and tests.
- Cuts to drug administration payments to excepted off-campus provider-based departments. This would expand a method first implemented to control volume and remove the site-of-service differential for drug administration at clinic visits by reducing payments to the Physician Fee Schedule equivalent rate. This will impact GI drugs administered via infusion.
The GI societies are conducting an in-depth review of the proposed policies to gauge the impact on GI. We will provide additional analysis about the rules soon, along with updates on how the proposed rules will impact you and how to get involved.
Resources
CMS Medicare Physician Fee Schedule Proposed Rule and Fact Sheets
2026 Physician Fee Schedule Proposed Rule
2026 Physician Fee Schedule Proposed Rule Press Release
2026 Physician Fee Schedule CY 2026 Proposed Rule Fact Sheet
2026 MPFS Proposed Rule GI and E-M Payment Changes
2026 MPFS Proposed Rule Work and Practice Expense RVU Changes
CMS Hospital Outpatient and ASC Proposed Rule and Fact Sheets
2026 OPPS/ASC Payment System Proposed Rule
2026 OPPS/ASC Payment System Proposed Rule Fact Sheet
2026 Hospital Outpatient Proposed Payment Changes
2026 Hospital Outpatient Top GI Code Proposed Payment Changes
2026 ASC Proposed Payment Changes
2026 ASC Top GI Code Proposed Payment Changes