Medicare Physician Fee Schedule (PFS) 2026 Overview: Key Updates and 2025 vs 2026 Comparison

OnCare360

Aug 30, 2025

The Medicare Physician Fee Schedule (PFS) is updated annually by CMS and establishes reimbursement, coding, and compliance rules under Medicare Part B. For 2026, CMS has introduced important changes that affect care management, monitoring, and coordination programs, including CCM, RPM, RTM, TCM, PCM, APCM, and BHI.

This article provides an educational overview of the 2026 PFS, with a comparison to 2025, and guidance on what practices should prepare for in the year ahead.

Why the PFS Matters

Determines reimbursement rates for all physician services under Part B.
Updates valuations for CPT/HCPCS codes used in chronic care and remote monitoring.
Defines documentation and supervision requirements.
Sets compliance standards that influence both Medicare and commercial payer contracts.

Key Updates in the 2026 PFS

1. Conversion Factor

2025: $32.25
2026: $31.98
→ A 0.8% decrease, reducing base reimbursement for most time-based services.

2. Chronic Care Management (CCM)

99490/99439 (standard CCM): Stable reimbursement.
99487/99489 (complex CCM): Revalued upward to reflect higher care intensity.
Impact: Stronger incentive to provide CCM for patients with complex needs.

3. Remote Patient Monitoring (RPM)

99453, 99454, 99457, 99458: Retained.
New Codes in 2026:
- 99XX4 – Device supply/data transmission for 2–15 days in a 30-day period.
- 99XX5 – 10–19 minutes of interactive management per month.
Impact: Expands billing opportunities for patients needing intermittent monitoring or shorter clinical interactions.

4. Remote Therapeutic Monitoring (RTM)

98975–98977, 98980–98981: Retained.
Clarifications in 2026:
- Broader applicability for musculoskeletal and respiratory conditions.
- General supervision rules reinforced for clinical staff.
- Alignment with RPM for short-duration monitoring (2–15 days).
Impact: Improves adoption for therapy-based care, especially in rehab and pulmonary programs.

5. Transitional Care Management (TCM)

99495 (moderate MDM, visit ≤14 days) and 99496 (high MDM, visit ≤7 days): Retained.
Reinforced requirements:
- Contact within 2 business days of discharge.
- Documentation of medication reconciliation.
Impact: Stable reimbursement, but stricter compliance expectations.

6. Principal Care Management (PCM)

99426, 99427: Retained.
Clarification: PCM must not overlap with CCM if both are billed.
Impact: Maintains viability for single-condition management while preventing duplication.

7. Advanced Primary Care Management (APCM)

G0556–G0558: Retained.
Documentation standards clarified to align with CCM/PCM.
Impact: Provides stability for practices delivering physician-led comprehensive care planning.

8. Behavioral Health Integration (BHI)

99484, 99492–99494: Retained.
Expanded emphasis on collaborative care and integration with primary care.
Impact: Sustains reimbursement while encouraging coordinated behavioral health models.

2025 vs 2026 PFS: Comparison

Program	2025 PFS	2026 PFS	Key Impact
CCM	Standard + complex CCM stable	Complex CCM revalued upward	Higher reimbursement for high-acuity patients
RPM	Codes required ≥16 days & ≥20 min	New codes 99XX4 (2–15 days), 99XX5 (10–19 min)	More flexible billing, broader eligibility
RTM	Codes available, limited uptake	Expanded conditions, supervision clarified, short-period alignment	Stronger adoption for therapy-based care
TCM	99495 & 99496 stable	Maintained, stricter documentation	Reinforced compliance
PCM	Codes retained	Retained, overlap with CCM restricted	Compliance clarity
APCM	Introduced in 2025 (G0556–G0558)	Retained with documentation standards	Sustainable adoption
BHI	Codes stable	Maintained with collaborative care emphasis	Stronger integration into primary care

Key Takeaways

Base reimbursement will decline slightly due to the lower conversion factor.
New RPM codes (99XX4, 99XX5) expand billing for shorter monitoring and brief management.
RTM gains clearer applicability and supervision rules, enabling greater use in therapy-driven care.
Complex CCM revaluation creates opportunities to better support high-need patients.
TCM, PCM, APCM, and BHI remain stable but require reinforced compliance.

Conclusion

The 2026 PFS underscores Medicare’s continued emphasis on chronic care management, monitoring, and coordinated services. Practices that align documentation and workflows with these updates can maintain compliance while capturing new opportunities.