Tag: Physician Fee Schedule
Final 2026 Medicare Conversion Factors: What Providers Need to Know
Understanding the difference between QP and non-QP conversion factors
Each year, the Centers for Medicare & Medicaid Services (CMS) finalizes updates that impact Medicare reimbursement under the Physician Fee Schedule (PFS). One of the most important updates is the Medicare Conversion Factor (CF) — the dollar amount used to convert Relative Value Units (RVUs) into the final payment amount.
For Calendar Year (CY) 2026, CMS finalized two separate conversion factors:
One for Qualifying Participants (QPs) in Advanced Alternative Payment Models (Advanced APMs)
One for Non-Qualifying Participants (Non-QPs)
This distinction is important because it directly affects reimbursement rates depending on a provider’s participation status in the Quality Payment Program (QPP).
Qualifying Participants (QPs)
A provider becomes a QP by meeting specific thresholds for participation in Advanced APMs, such as having a certain percentage of payments or patients through eligible Advanced APM arrangements.
Key point: QPs receive a more favorable conversion factor update than non-QPs.
Non-Qualifying Participants (Non-QPs)
Providers who do not meet QP thresholds—or who participate in MIPS instead—fall into the non-QP category.
Bottom Line:
The Final 2026 Medicare Conversion Factors reinforce a major policy direction: CMS continues to differentiate payment updates based on participation in Advanced APMs.
Understanding whether your clinicians are QPs or non-QPs is essential for accurate reimbursement forecasting and strategic planning.
Conversion Factor:
- $33.57 for qualifying alternative payment model (APM) participants (QPs)
- $33.40 for non-QPs
- An increase of 3.77% for QPs and 3.26% for non-QPs over the 2025 rates
- Includes 0.75% increase for QPs and 0.25 for non-QPs
- 0.49% positive budget neutrality adjustment
- 2.50% increase from the OBBBA for 2026
NEW BCBSTX fee schedule coming
ATTENTION PROVIDERS
BCBSTX has notified POET that a NEW Fee Schedule for Blue Choice and Blue Essentials will be effective May 1, 2026.
Once POET receives the new fee schedule and completes its review, OPT-IN / OPT-OUT packets will be sent to physician offices for participation decisions.
Please watch for additional communication once the review process is complete
How to Search the BCBS Fee Schedule for Quarterly HCPCS (Updated)
Choose “Standards and Requirements”
Then “General Reimbursement Information”
Scroll to the Bottom and enter the password “Manual”, then click submit
Read the Policies Disclaimer or scroll to the bottom and click “Continue”
Then choose “Blue Choice PPO, Blue Essentials, Blue Premier, Blue Advantage HMO, MyBlue Health, Blue High Performance Network Schedules”
Directly under that, select “2024 Schedules effective 2/1/2024”
Scroll down to “CPT/HCPCS Drug Schedule” click
The schedule will open in a PDF. You may search by using “CTRL F”
Aetna Fee Schedule Update Effective Today
However, Aetna tells POET the fee schedule is not ready for them to send out, yet.
Having Trouble Locating BCBS 1st Qtr HCPCs?
POET has heard from Genesis our BCBS Network Management Consultant. 2024 HCPCs schedules are still in effect. The 1st quarter update will be effective March 1, 2025.
TMA Webinar Helps Equip Physicians for 2025
Medicare Fee Schedule
With the Centers for Medicare & Medicaid Services’ (CMS’) 2025 Medicare Physician Fee Schedule set to take effect Jan. 1, the Texas Medical Association is preparing physicians for changes in payment and coding, telemedicine, and quality and value-based care arrangements, among other areas.
Medicare Solidifies Pay Cut
In a final rule that solidifies a nearly 3% Medicare pay cut for physicians in 2025, the Centers for Medicare & Medicaid Services (CMS) also set the trajectory for physician practices over the next year with a mixed bag of changes related to telemedicine, coding and payment, and the Merit-Based Incentive Payment System (MIPS), among others. ~By Phil West
While TMA analyzes what it sees as some isolated, positive changes resulting from CMS’ finalization of the 2025 Medicare Physician Fee Schedule, it is also urging physicians to act now to show their support for House Resolution 10073
Good News, Bad News in Medicare 2025
A first look at the 2025 Physician Fee Schedule
The 2025 Physician Fee Schedule proposed rule is a study in contrasts. If you’re the kind of person who can see both sides of an issue, this rule is for you.
Good News
Bad News
Practitioners doing telehealth from their home can continue to use the practice address instead of their home address on claims for 2025
Without an act of Congress, for real time audio/visual visits on 1/1/2025 patients can no longer receive these services in their homes in all geographic areas. Patients must be in an underserved area and go to a facility setting for telehealth. (Unless Congress changes this in their end of year Consolidated Appropriations Act.)
16 new telehealth codes that can be selected based on Medical Decision Making (MDM) or time.
Medicare has given them a status indicator of invalid.
New HCPCS code for GIDXX for visit complexity inherent to in patient and observation services associated with a confirmed or inspected infectious disease. (GIDXX is a placeholder code, not a final code.)
Limiting use. “We anticipate the HCPCS code GIDXX would be reported by physicians with special infectious disease training”
Can use G2211 when you use modifier 25 for an E/M and wellness visit on the same day, immunizations, and other preventive medicine services.
That’s the only exception.
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