2026 Medicare Fee Schedule: What Practices Need to Know
2026 Medicare Fee Schedule: What Practices Need to Know
Every fall, CMS releases the proposed Medicare Physician Fee Schedule (PFS) for the following year, and every year the same story plays out: a statutory formula produces a conversion factor cut, Congress debates whether to act, and — usually late in the year or in the first weeks of the new year — legislation patches the cut, partially or fully. The result is that practices routinely enter January unsure of what Medicare actually pays, and then receive retroactive adjustments after a fix is signed into law.
That pattern matters for planning. This post covers what practices should understand about 2026 fee schedule dynamics, the telehealth policies extended through this year, and two code changes that affect billing for evaluation and management services.
The Conversion Factor: An Ongoing Policy Question
The Medicare conversion factor is the dollar amount multiplied by a procedure’s relative value units (RVUs) to produce the fee schedule payment. It has been subject to downward pressure for years under the sustainable growth rate formula’s successor, the statutory payment update mechanism. Potential cuts of several percent have been announced in proposed rules, then partially reversed through Congressional action in most recent years.
For 2026, practices should verify the current conversion factor directly from CMS rather than relying on projected figures. The authoritative source is the CMS Physician Fee Schedule page at https://www.cms.gov/medicare/payment/fee-schedules/physician, which is updated as final rules and any subsequent legislation take effect.
The practical implication for billing: if your practice management system populates Medicare allowables automatically, confirm that updates are current. Billing staff who set expected payment benchmarks based on stale fee schedule data will generate inaccurate A/R expectations and may miss underpayments from Medicare Advantage plans that benchmark to the PFS.
Telehealth: Extended Coverage Through 2026
Telehealth flexibilities that were introduced during the COVID-19 public health emergency have been repeatedly extended by Congress rather than allowed to expire. For 2026, several key provisions remain in effect.
Originating site restrictions — which had historically limited telehealth coverage to patients in rural areas seen at specific facility types — remain waived for most services. Patients can receive covered telehealth services from their home, which opened telehealth to the full Medicare population, not just those in rural geographies.
Audio-only visits remain covered for patients who lack access to video technology or cannot use it, provided the clinical service is appropriate for that format. Documentation should reflect the patient’s communication method.
Place of service (POS) code selection matters for telehealth billing. POS 02 (telehealth provided other than in a patient’s home) and POS 10 (telehealth provided in a patient’s home) distinguish where the patient was located. Selecting the wrong POS code is a common and correctable denial cause — payers including Medicare, Aetna, and BCBS have been consistent on this distinction. Modifier 95 (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) should accompany the procedure code for most video visits.
For practices billing mental health services via telehealth, the in-person visit requirement — which had been proposed to require patients to have an in-person visit within six months of establishing telehealth mental health services — has been subject to ongoing delays and modifications. Verify the current status before relying on a documentation pattern set in prior years.
G2211: The Complexity Add-On
CPT add-on code G2211 was finalized for use with office and outpatient E/M visits (99202-99215) to recognize the additional resources required for patients who are seen on an ongoing basis for a single serious condition or a complex condition.
G2211 can be billed with a 99213 or 99214 when the visit is part of an ongoing relationship with a patient who has complex care needs. The intent is to recognize longitudinal primary or specialty care that is more work than a single-visit encounter, without requiring the provider to upcode the base E/M level.
Documentation for G2211 should reflect the ongoing nature of the relationship and the complexity of the patient’s condition. Billing G2211 on every visit without documentation of the condition’s complexity or the care relationship will invite review from Medicare and Medicare Advantage plans. UHC and Cigna have followed Medicare’s lead on G2211 coverage policies, though plan-level variation exists.
Behavioral Health Integration Codes
CMS has continued to support billing for collaborative care and behavioral health integration through a set of care management codes. Practices that have integrated behavioral health staff into a primary care setting can bill monthly care management codes for patients with a behavioral health condition — commonly depression (F32.9, F41.1) or anxiety being managed under a registry-based collaborative care model.
These codes cover non-face-to-face care management activities: initial patient contact, care planning, registry tracking, and coordination between the primary care provider and the behavioral health care manager. Billing requires that the practice have a systematic care management process in place, not just occasional coordination.
For practices that treat a significant volume of patients with behavioral health conditions, these codes can represent meaningful revenue that is often underutilized simply because the care management workflow is not connected to the billing process.
What Billing Staff Should Do Now
Fee schedule changes cascade through billing operations in ways that are easy to miss if no one owns the update process. Recommended steps: confirm the current Medicare conversion factor in your billing system; verify POS and modifier conventions for your telehealth claims; review your G2211 utilization rate against documentation; and check whether your behavioral health integration workflow — if you have one — is connected to the care management billing codes.
For the authoritative fee schedule data, bookmark the CMS Physician Fee Schedule lookup at https://www.cms.gov/medicare/payment/fee-schedules/physician and check it after any major legislative action.
This post was drafted by AI and reviewed by our editorial team. Last updated 2026-05-30.