The 2026 Physician Fee Schedule (PFS) Final Rule issued by the Centers for Medicare and Medicaid Services (CMS) contains very few changes from the Proposed Rule released in July. Although the Conversion Factors (CF) are an increase over the current 2025 rate, they are slightly lower than in the Proposed Rule.

For the first time, there will be two different fee schedules in 2026 determined by a provider’s participation status in Alternative Payment Models (APM). The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA 2015) contained a requirement that participants in APM’s would receive an additional 0.75% annual update beginning in 2026, while non-APM participants would receive a 0.25% annual update. The CF for Qualified Professionals (QP) will be $33.5675 rather than $33.5875 in the Proposed Rule and for non-QP’s the CF will be$33.4009 rather than $33.4209 in the Proposed Rule.

Both CF calculations apply a positive 0.49% budget neutrality factor and a 2.50% increase that was contained in the July 2025 budget act (OBBBA), for a base CF increase of 3.0%. After the new APM participation updates the final CF will be an increase of 3.77% for QP’s and 3.26% for non-QP’s.

Many radiology practices are unable to participate in Alternative Payment Models (APM) as part of the Quality Payment Program (QPP). Therefore, it is likely that the majority of practices will receive reimbursement at the lower of the two rates for 2026.  

The published CMS estimates of the rate of impact for radiology specialties are unchanged from the values in the Proposed Rule. These estimates are based on changes in RVU values, but they do not account for changes in the Conversion Factor. As we explain further below, the estimated impact will vary significantly depending on the site of service, as follows:

Efficiency Adjustment

The Final Rule confirms that the MPFS will include a -2.5% Efficiency Adjustment that would generally apply to all codes except time-based codes such as Evaluation and Management (E/M) services and services on the telehealth list. New procedure codes will also be exempted. These adjustments will take place every three years, using the Medicare Economic Index (MEI) productivity adjustment percentage with a lookback period of five years. According to analysis of the Proposed Rule by the American Medical Association (AMA), only 393 services will be exempt from the efficiency adjustment and most specialties will see a payment reduction of 1%.

Site of Service Adjustment

Beginning in 2026, the MPFS will begin to shift reimbursement away from services provided in a facility (hospital) setting and toward office-based services by reducing the portion of the facility Practice Expense (PE) RVUs allocated based on work RVUs to half the amount allocated to non-facility PE RVUs. However, the Final Rule confirms our earlier reporting that that this Site of Service Differential will not apply to services billed with Modifier -26. Thus, hospital-based radiologists will not be negatively impacted directly but those who are employed by hospitals could feel future pressure as the institution’s technical component is reduced, affording them a smaller pot from which to pay the employed radiologists. Radiology practices billing globally for office-based services could benefit from the shift.

Geographic Practice Cost Indices (GPCI)

A Continuing Resolution (CR) passed by Congress in March 2025 extended the 1.0 work floor factor that is used to calculate the geographic adjustment of the Medicare fee schedule through September 30, 2025, and no action has been taken by Congress to extend it. As noted by CMS in the Final Rule, “The 1.0 work GPCI floor is established by statute and expired September 30, 2025. CMS does not have the authority to extend the 1.0 work floor.”  The Geographic Adjustment Factor (GAF) tables contained in the Final Rule do not reflect the 1.0 work floor. See our article for more details on the GAF.

Supervision Requirements

The MPFS Final Rule makes permanent the supervision flexibilities granted in 2020 during the COVID-19 pandemic. Physician offices and IDTF’s will have the ability to directly supervise certain diagnostic tests, such as Level 2 contrast administration, using real-time audio and visual interactive telecommunications technology. Note that both audio and video are required; audio-only connectivity is not sufficient.

Quality Payment Program

Similarly to the MPFS fee schedule changes, the 2026 rules that govern the Quality Payment Program (QPP) are not very different from what was in the Proposed Rule. The Final Rule confirmed that there will be 6 new MIPS Value Pathways (MVP) applicable to radiology, including pathways for both diagnostic and interventional radiology. There are 6 MIPS quality measures and 3 QCDR quality measures, 11 improvement activities, and one cost measure in the diagnostic radiology MVP. The interventional radiology MVP will have 6 MIPS quality measures and 4 QCDR quality measures, 19 improvement activities, and 3 cost measures.

Most of the other aspects of the MIPS rules remain unchanged for 2026, including the MIPS Performance Threshold which will remain at 75 points through performance year 2028. This is the level of points needed in 2026 to avoid a negative payment adjustment in 2028. The maximum negative adjustment will remain at -9%, with no provision in current law for future changes. The actual positive adjustment in 2028 available for QPP participation in 2026 cannot be determined until the reporting period is over.

The Final Rule affirms the Quality Category measure scoring policy established in 2025 that identifies certain measure sets affected by limited measure choice and adjusts the benchmarks of point-capped measures to allow for a maximum score of 10 points, extending the policy to MVP’s.

Other changes to the QPP rules include:

• Groups will have to attest to their specialty composition during the MVP registration process. CMS will no longer make this determination automatically.
• Health Equity will be removed from the list of high priority Quality measures.
• Achieving Health Equity will be removed from the list of Improvement Activities and replaced by a new Advancing Health and Wellness subcategory.

Participants in Advanced APMs are eligible for the enhanced fee schedule described above. Previously, the determination of Qualified Participant (QP) status was made at the group level, but beginning in 2026 such determination will be made at the individual level as well.

Conclusion

The Final Rule mirrors the provisions laid out in the Proposed Rule with little change. The CF was modified slightly downward due to final calculations being applied. The Efficiency Adjustment of -2.5% generated a lot of concern and advocacy activity among professional societies when it came out in the Proposed Rule but ultimately they did not influence CMS’s final decision.

We will continue to analyze the impact of the MPFS Final Rule on radiology practices. Subscribe to this blog for all the latest information that affects your practice’s reimbursement.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

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