In 2026, you may notice shifts in your Medicare and commercial reimbursement. These shifts result from several payment policies enacted by Medicare in 2026 and ongoing policies in the commercial sector.
Medicare 2026 Policies
Medicare physician payments are determined using a resource-based relative value scale (RBRVS), which calculates payment by summing three Relative Value Units (RVUs)—physician work, practice expense (PE), and malpractice (PLI) insurance, adjusting for geographic cost differences (GPCI), and multiplying by a conversion factor.
2026 Medicare Conversion Factor (CF)
For the first time in five years, the Centers for Medicare and Medicaid Services (CMS) implemented a positive update to the Medicare Conversion Factor (CF) for 2026. For most clinicians, CMS finalized the CY 2026 CF at $33.4009, an increase from the CY 2025 CF of $32.3465. This represents a 3.26% increase over CY 2025. For clinicians who meet participation thresholds in Advance Payment models, the CF is $33.57.
Although the CF rose slightly for CY 2026, the final rule also includes policies that could reduce payments for many gastroenterologists!
2.5% Reduction Applied to Work RVUs
CMS also finalized a misguided “efficiency adjustment” policy that applies a 2.5% cut to work RVUs for endoscopy and other non-time-based codes. The rationale for this cut to work RVUs is that CMS believes clinicians become increasingly efficient over time, and that codes are not reviewed often enough to capture these efficiencies. In response, the agency is applying this across-the-board cut to work RVUs.
Note that this cut does not apply to evaluation and management (E/M) services. ACG estimates that approximately 20% of GI Medicare Part B allowed charges are for E/M services. The actual share of E/M services provided by a GI practice will vary by patient mix. Generally, practices that provide more chronic care management will report more E/M services. These practices may be less affected by the efficiency adjustment.
🚨 Advocacy Alert: New Bill to Delay ‘Efficiency Adjustment’ 🚨
Reps. Ron Estes (R-KS) and Tom Suozzi (D-NY) recently introduced the Efficiency Adjustment Delay Act (H.R. 7520), which pauses the arbitrary RVU cuts until 2030 and places restrictions on CMS’ ability to implement this unfair policy.
The most effective way to make an impact? A quick phone call to your Member of Congress.
Site of Service Payment Differential Benefitting Office-Based Services
In 2026, office-based procedures are seeing increases in reimbursement, while the same services performed in a facility setting (hospital outpatient department or ambulatory surgical center (ASC)) are seeing decreases. This is due to a technical change in how CMS calculates PE RVUs, under which services performed in a facility setting do not include the costs of maintaining an office. In a budget-neutral environment, these practice costs are shifted to the PE RVUs for services performed in a non-facility (office-based) setting. As a result, office-based PE RVUs are increasing while facility-based PE RVUs are decreasing.
The GI societies and our members have warned CMS about the proposal’s impact on high-quality GI care. This new policy also fails to distinguish between hospital-employed physicians and private-practice physicians, or between private-practice physicians who typically perform procedures in an ASC. These physicians, although they provide services in a facility, still incur office maintenance costs, yet the new PE RVU methodology does not account for these costs.
Commercial Plans Audits on E/M Services
Before you go throwing away your endoscope for a stethoscope, GI practices have also recently been facing reports of commercial “downcoding audits” aimed at lowering Level 4 and 5 Evaluation and Management (E/M) visits to Levels 2 and 3. This scrutiny looms over office settings in the commercial side of your patient mix, even as Medicare reduces work and practice expense RVUs in the facility setting. What’s at stake, and how should you prepare your practice?
Assessing Your Risk of an Audit
It is good business practice to conduct ongoing testing and evaluation to assess your risk of a coding audit. A key element is determining whether your practice’s E/M reporting is inconsistent with benchmarks for other GI practices. ACG reviewed publicly available Medicare data to estimate reporting benchmarks for E/M services among GI practices.
New Patient Visit CPT Codes Reported by GI Physicians: % Reported of All New Patient E/M Codes Reported
| 99202 | 99203 | 99204 | 99205 |
| 4.92% | 33.75% | 55.62% | 5.72% |
Established Patient Visit CPT Codes Reported by GI Physicians: % Reported of All Established Patient E/M Codes Reported
| 99211 | 99212 | 99213 | 99214 | 99215 |
| 2.29 | 3.64 | 39.17 | 49.71 | 5.19 |
Is your practice’s E/M breakdown comparable to Medicare’s GI data for levels 4 and 5 E/M services? If you see more patients with higher E/M code levels, you may be considered an outlier and at risk for commercial payer scrutiny. There may be reasons your billing deviates from the norm, but determining whether you are within or outside the norm is the first step. The next step is to ensure that the justification for the billing is included in the medical documentation.
E/M Billing Guidance
Proper documentation and adherence to E/M coding guidance are essential as commercial insurers continue to use “downcoding” tactics against GI practices. According to CMS, “incorrect coding accounted for 49% of improper payments for E/M codes during the 2024 reporting period, while insufficient documentation (34.1%), no documentation (13.1%), and other errors (3.7%) also caused improper payments.” Thus, it is important that your practice follows the proper coding and documentation requirements when billing E/M services.
Here are some E/M educational resources to support your analysis:
- ACG and the GI societies provided guidance when E/M codes were revised in 2021, which you can view here.
ACG would like to thank Sheila Madhani (Madhani Healthcare Consulting, LLC) for her contributions in drafting this article and E/M code analyses.