Each year, the Centers for Medicare & Medicaid Services’ (CMS) issuance of its proposed rule for the Medicare Physician Fee Schedule (PFS) creates potentially significant changes to PFS payments and Part B in particular. The impact of these proposed changes can be widespread and complex, and it is important to understand how these changes may affect you or your practice. Significant proposed changes to the 2026 PFS include, but are not limited to:
- Telehealth Services:
CMS proposed to streamline the process of adding services to the Medicare Telehealth Services List by removing the distinction between provisional and permanent services and by limiting its review to whether the service can be furnished using an interactive, two-way audio-video telecommunications system. CMS also proposed to:
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- permanently adopt 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); and
- allow “direct supervision” for certain applicable incident-to services; diagnostic tests; and pulmonary, cardiac, and intensive cardiac rehabilitation services.
- Skin Substitutes:
CMS spent billions of dollars last year under Part B for skin substitutes in non-facility settings. Consequently, CMS is now conducting sweeping audits of providers who use these products and is clawing back millions of dollars. To manage these costs, CMS proposed to:
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- pay for skin substitutes as incident-to supplies when used as part of a covered application procedure under the PFS in the non-facility setting or under the Outpatient Prospective Payment System (OPPS) in the hospital outpatient department setting; and
- categorize skin substitutes according to their U.S. Food and Drug Administration (FDA) regulatory statuses and use a single payment rate to reflect the highest average based on these statuses.
- Care for Chronic Illness and Behavioral Health:
In an ongoing effort to address the growing challenges surrounding chronic illness and behavioral health, CMS proposed to:
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- create three optional add-on codes for Advanced Primary Care Management services to facilitate providing complementary behavioral health integration or psychiatric Collaborative Care Model services; and
- expand access to the Medicare Diabetes Prevention Program as well as payment policies for digital mental health treatment devices used in the treatment of Attention Deficit Hyperactivity Disorder.
- Practice Expense Methodology Changes:
Given concerns about the completeness of the American Medical Association survey data upon which the current methodology relies, CMS proposed to:
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- recognize greater indirect costs for practitioners in office-based settings compared to facility settings; and
- use auditable, routinely updated hospital data from the OPPS to set relative rates for technical services paid under the PFS.
Simon Chaykler, Documentation and Coding Compliance Advisor, of Garfunkel Health Advisors, Inc. (GHA) notes that, “Staying current with evolving rules and regulations is critical for ensuring compliance, maximizing reimbursement, and maintaining high-quality patient care.” David Traskey, a Partner at Garfunkel Wild, agrees noting, “In this rapidly changing environment, keeping up-to-date reduces the likelihood of billing errors, potential audits, or other legal risks. Even the smallest proposed changes can be dangerous if you are unaware.” Understanding the latest regulations, whether proposed or final, also allows practices to expand patient access, integrate new technologies safely and efficiently, and increase revenue.
The comment period for these proposed changes closes Friday, September 12, 2025. Be sure to share your thoughts with CMS before this deadline.
Should you have any questions regarding the above or wish to learn more about how GHA can help you, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or GHA directly at [email protected].
