CMS Issues 2026 Physician Fee Schedule Promoting Primary Care, Behavioral Health and Chronic Disease Management

By: Rolf Lowe

November 2025

On October 31, 2025, The Centers for Medicare & Medicaid Services (CMS) issued the final rule for the physician fee schedule (PFS) for calendar year (CY) 2026. The PFS is updated and published annually in the Federal Register. In addition to setting prices for Medicare reimbursement, the PFS also includes updated payment and coverage policies for Medicare reimbursable services and supplies, and the implementation of provisions from various Congressional Acts that have been passed over the previous years. The final rule adopted most of what was included in the proposed rule when it was released in July.

In a press release from CMS released on the same day as the final rule, Chris Klomp, CMS Deputy Administrator and Director of the Center for Medicare, stated that “CMS is reinforcing primary care as the foundation of a better healthcare system while ensuring Medicare dollars support real value for patients, and not the kind of waste or abuse that erodes trust in the system.” In addition, CMS also identified that they are aligning with Health and Human Services Secretary Robert F. Kennedy’s initiative to Make America Health Again by refocusing existing risk assessment payment policies on essential patient behaviors in order to reduce chronic diseases, improve patient health and nutrition, as well as improve their physical activity.

With this renewed focus comes five quality measures within CMS’ quality programs focusing on the prevention of chronic disease, including screening for prediabetes. With the emphasis on prevention, and in effort to reduce administrative burdens on providers, CMS is also removing ten quality-based measures that did not appear to ha ve a significant impact on patient outcomes. Changes are also being made to the Medicare Diabetes Prevention Program, allowing more people with Medicare access to coaching and peer support, as well as assistance with dietary, behavioral and physical needs through training and change strategies. This is part of the renewed focus to help prevent the onset of Type 2 diabetes and prediabetes.

In the behavioral health realm, CMS continues to emphasize the integration of physical health and behavioral health in the 2026 PFS. For CY 2026 CMS is currently finalizing three new G codes for the Health Care Common Procedure Coding System (HCPCS) Index in the area of Advanced Primary Care Management (APCM). The intention is to facilitate the provision of complementary behavioral health integration (BHI) or psychiatric Collaborative Care Model (CoCM) by creating optional add on codes for providers to use, and which can be billed as add-on services, when the ACPM base code is reported by the same practitioner in the same month of service.

A new payment model has also been introduced for certain high-cost chronic conditions that will begin in CY 2027. The pa yment model is identified as the Ambulatory Specialty Model and is concentrated on patients with heart failure and low back pain. The focus of this model is enhancing quality of care, and improving beneficiary and provider engagement. This is being accomplished by incentivizing preventative care and increasing financial accountability for specialists. Specialists who detect signs of worsening chronic conditions early on, enhance a patient’s overall function, limit or reduce avoidable hospitalizations and utilize technology to communicate and share data with patients and their primary care providers will be rewarded through this new payment model. The model is expected to run for five performance years.

Providers are also seeing a modest increase in reimbursement calculations across the board. CMS has made a distinction in the increases though, paying providers who participate within qualifying Alternative Payment Models (QPs) under separate conversion factors. QPs participating in Advanced Alternative Payment Models should see an average increase of 3.8%, while non QPs should see an average increase of 3.62%. It should be noted that these changes are to the conversion factor CMS utilizes for reimbursement, and do not necessarily equal a corresponding increase to each individual service rate that is paid.

The above is just an example of some of the changes and updates in the 2026 PFS , with areas like telehealth, evaluation and management services, skin substitutes and facility and non-facility reimbursement being addressed. For additional information or assistance on this subject, or other areas of healthcare law, please contact Rolf Lowe of Wachler & Associates at (248) 544- 0888 or lowe@wachler.com.