CMS Changes for 2026: What Medical Coders Need to Know
As healthcare policy continues to evolve, the Centers for Medicare & Medicaid Services (CMS) has finalized significant regulatory and coding updates for Calendar Year (CY) 2026. Medical coding CMS changes for 2026 affect the Medicare Physician Fee Schedule (MPFS), CPT/HCPCS codes, documentation requirements, reimbursements, and other Medicare Part B and outpatient payment policies. Many provisions go into effect January 1, 2026. Federal Register
Major Payment Policy Shifts in the 2026 Medicare Physician Fee Schedule
Conversion Factor Changes
One of the most consequential changes is the update to the Medicare physician fee schedule conversion factor (CF):
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CMS finalized a base CF of about $33.40 for most clinicians.
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A slightly higher CF of $33.57 applies to clinicians participating in qualifying alternative payment models (APMs).
This represents a notable increase compared to 2025, while incorporating statutory adjustments from Congress and a productivity/efficiency adjustment.
Specialty vs. Primary Care Payment
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While primary care and certain independent practices see relative gains under the new schedule, many facility-based and specialist services experience payment reductions due to efficiency adjustments and site-of-service valuation differences.
CPT/HCPCS Code Changes for 2026
Annual CPT/HCPCS Update
CMS annually aligns Medicare coding with the latest AMA CPT codes and HCPCS Level II updates. For 2026:
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288 CPT codes are newly added or revised, with deletions and editorial changes across multiple specialties.
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The Physician Self-Referral Code List has been updated to reflect new and deleted CPT/HCPCS codes for compliance with Stark Law reporting. Centers for Medicare & Medicaid Services
These changes carry direct billing and compliance implications, particularly for labs, imaging, therapy services, and emerging technologies.
Documentation & Coding Rule Refinements
E/M Coding and Documentation
CMS has refined some E/M coding guidelines to emphasize greater specificity and documentation integrity:
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Clearer definitions for medical decision-making levels.
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Tighter review and validation of time-based billing, especially for prolonged services.
Accurate documentation is now more critical than ever for defending code assignments against audits and ensuring appropriate reimbursement.
Medicare Part B and Ancillary Billing Updates
Average Sales Price (ASP) Policies
CMS finalized changes to how ASP is calculated for Part B drugs, ensuring that units sold at the maximum fair price are included in ASP calculations beginning in 2026. This affects reimbursement levels for infused or injectable medications.
340B and Part D Rebate Rules
CMS has finalized a claims-based method for excluding 340B units from Part D rebate calculations, establishing a data repository for Part D claims with dates of service in 2026 and beyond.
RHC & FQHC Coding
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) must report individual component CPT codes for Collaborative Care Model and Communications Technology-Based Services instead of bundled codes for separate payment.
OPPS & ASC Payment Policy Developments
Though separate from physician fee schedule changes, coders working in hospital outpatient departments (OPPS) and ambulatory surgical centers (ASC) must be aware of:
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2.6% increase to OPPS payment rates for 2026 after productivity adjustments.
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Continued phase-out of the inpatient-only (IPO) list and expansion of site-neutral payment policies.
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A 0.5% reduction in the OPPS conversion factor to correct past 340B overpayments.
Compliance, Audits & Risk Management
CMS is increasingly focusing on documentation integrity and compliance risk:
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Enhanced edits and monitoring for overlapping services.
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Tightening of rule interpretations to prevent overpayments and erroneous billing.
Coders should audit internally for:
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Proper E/M level support.
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Correct bundling and unbundling.
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Appropriate modifiers and time-based billing justification.
Final Tips for Coders & Billers in 2026
Prepare Your Practice
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Update internal coding manuals with the 2026 CPT/HCPCS sets.
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Conduct staff training on documentation changes and E/M refinements.
Review Payer Policies
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Verify Medicare Administrative Contractor (MAC) guidance for local coverage differences.
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Reconfirm proper claim submission for services impacted by site-neutral and bundled payment shifts.
Track Regulatory Updates
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Follow CMS flash reports and Federal Register notices for late-breaking changes that may occur throughout 2026.
CMS’s 2026 updates bring sweeping impacts across:
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Medicare physician payment rates and conversion factors.
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New, deleted, and revised CPT/HCPCS codes aligned with practice evolution.
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Documentation emphasis, audit vulnerability, and compliance risk.
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Part B reimbursement policies and drug pricing methodology.
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OPPS and ASC payment methodologies.
Proactive training, strong documentation practices, and up-to-date policy knowledge will be essential for accurate coding and optimized reimbursement in 2026 and beyond.