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According to an announcement from the Centers for Medicare & Medicaid Services (CMS), the Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule includes suggested changes to the Medicare Shared Savings Program. The goal is to make timely improvements to program policies and operations.
In addition to MSSP changes, a variety of possible changes would not only affect the amount physicians are paid but also have direct and indirect impacts on providers offering Medicare care management programs. If finalized, the proposed changes would take effect January 1, 2026.
We’ve selected the most salient proposed changes to outline here and plan to host a webinar to discuss them further in the near future.
Payment includes increase, but paid at two levels
CMS is proposing that the conversion factor for Relative Value Units (RVUs) be paid at two different levels: one for physicians in qualifying Alternative Payment Models (APMs) and those in nonqualifying APMs.
- Physicians in qualifying APMs would be paid a conversion factor of $33.59, which is a 3.83% increase over $32.25 paid in 2025.
- Physicians in nonqualifying APMs would be paid a conversion factor of $33.42, which is a 3.62% increase over $32.25 paid in 2025.
In addition to conversion factor updates, the proposed rule focuses on:
- Updating payment models toward awarding efficiency
- Making permanent many COVID-era flexibilities for telehealth
- Providing guidance regarding fair market valuations in connection with bona fide service fees used to calculate drug manufacturers’ Average Sales Price
Proposed changes directly affecting Medicare care management programs
If approved, we consider the following five changes to be have the most material to direct impact on ThoroughCare clients and colleagues.
Advanced Primary Care Management: Three new add-on codes for behavioral health
In the 2025 PFS final rule, CMS confirmed separate coding and payment for Advanced Primary Care Management (APCM) services, including HCPCS codes G0556, G0557, and G0558.
Section II.G. of the Proposed Rule recommends three new add-on codes (GPCM1, GPCM2, GPCM3) to integrate behavioral health services into Advanced Primary Care Management without requiring time-based documentation.
CMS plans to value these codes by directly crosswalking from existing Behavioral Health Integration (BHI) and collaborative care model (CoCM) codes, as shown below.
RVU value crosswalk
- CPT code 99492 for HCPCS code GPCM1 (work RVU 1.88)
- CPT code 99493 for HCPCS code GPCM2 (work RVU 2.05)
- CPT code 99484 for HCPCS code GPCM3 (work RVU 0.93)
Their stance is that the “physicians and practitioners who furnish APCM services should be able to provide BHI services and CoCM without needing to document their time spent performing the service because this would help facilitate a more holistic, team-based approach to care coordination and reduce burden.”
G0136: Remove code for Social Determinants of Health (SDOH) risk assessment
CMS proposes eliminating HCPCS code G0136, which is for the administration of a standardized, evidence-based Social Determinants of Health risk assessment tool, specifically for services lasting 5-15 minutes.
This code has been used when a practitioner has reason to believe there are unmet SDOH needs that could interfere with the diagnosis or treatment of a patient. Currently, G0136 is on the Medicare Telehealth Services Under Section 1834(m) of the Act (section II.D.).
CMS suggests that G0136 is duplicative of services covered under evaluation and management codes. Their position is that the assessment is “not intended for routine screening, but rather for assessing a patient's known or suspected social needs.”
Additionally, CMS recommends replacing the term SDOH with "upstream driver(s).”
As stated in the proposed rule, “We have determined that the term ‘upstream driver(s)’ is more comprehensive and includes a variety of factors that can impact the health of Medicare beneficiaries. The term ‘upstream driver(s)’ encompasses a wider range of root causes of the problems that practitioners are addressing through CHI services. This type of whole-person care can better address the upstream drivers that affect patient behaviors (such as smoking, poor nutrition, low physical activity, substance misuse, etc.) or potential dietary, behavioral, medical, and environmental drivers to lessen the impacts of the problem(s) addressed in the initiating visit.’
This change would update language in specific coding descriptors, including those for Community Health Integration (CHI) and HCPCS code G0019.
Remote Patient Monitoring/Remote Therapeutic Monitoring: Valuation changes for specific CPT codes
CMS disagreed with several of the American Medical Association’s Relative Value Scale Update Committee (RUC) recommendations regarding Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM).
CMS cited that the RUC did not meet the minimum survey requirements established; however, they will resurvey physicians after one year of utilization data is available to determine if code refinement is merited.
CMS proposed their own work RVUs for the following CPT codes for RPM services: 99091, 99XX5, 99457, and 99458.
Some CMS recommendations increased the work RVUs, and others decreased them. For the remainder, CMS agreed with RUC’s recommendations.
CMS proposed their own work RVUs for the following CPT codes for RTM services: 98XX7, 98980.
CMS recommends lowering the RVU for 98XX7 and maintaining the current work RVU for 98980.
Separate from proposed RVU changes, CMS would like to maintain the current clinical staff type for RTM codes to registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MTAs), and not include physical therapy assistants.
Rural Health Clinics/Federally Qualified Health Centers: Unbundling BHI-related codes G0512 and G0071
Outlined in section III.B., CMS is proposing unbundling BHI-related codes G0512 for the Psychiatric Collaborative Care Model (CoCM) and G0071 for virtual communication services.
This would require participating Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to bill for the individual CPT codes that currently make up G0512 and G0071, as shown in Table 1 below.
Similar to the final changes that unbundled G0511 for care management in 2025, rural providers would bill for the individual CPT and HCPCS codes that make up HCPCS G0512.
The current list of base codes and add-on codes that make up G0512 is excerpted below in Table 1 from Table 34 in the Proposed Rule.
Payment for these services would be based on the national non-facility PFS payment rate.
Table 1: Excerpted from Table 34 in the Proposed Rule.
The proposed rule states the following, which we believe is salient for rural providers to be aware of: “Any new care coordination HCPCS codes will be paid separately from the RHC AIR methodology or FQHC PPS at the national non-facility PFS payment rate, either alone or with other payable visits.
We note that some of the current RHC and FQHC care coordination services are not listed on the current list of designated care management services, however, we will continue to make separate payments for these RHC and FQHC care coordination services as they have been previously adopted through notice and comment rulemaking. These services include CCM, PCM, BHI, CPM, RPM, RTM, CHI, PIN and PIN-peer support services, and APCM.”
RHCs/FQHCs: Making a distinction between care management and care coordination
CMS is drawing clarified distinctions between care management and care coordination services, especially in the context of Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
While these terms were once used interchangeably, going forward, CMS proposes greater clarity with care management referring more broadly to clinical services like Chronic Care Management (CCM), Behavioral Health Integration (BHI), and Remote Patient Monitoring (RPM), which often require the involvement of clinical staff.
In contrast, care coordination focuses on non-face-to-face administrative and logistical tasks that help ensure patients receive timely, cohesive care across different providers and settings—tasks that typically don’t require a licensed practitioner.
To support this shift, CMS is recommending that all new care management services finalized under the Medicare Physician Fee Schedule (PFS) also be classified as care coordination services for RHCs and FQHCs.
This would allow these clinics to bill for care coordination separately from regular patient visits, ensuring they’re compensated for the behind-the-scenes work that keeps patients healthy and out of the hospital.
CMS also aims to improve transparency by updating the list of payable services each year through sub-regulatory guidance like manuals and website updates—offering providers more predictable, streamlined billing information.
By formally recognizing and reimbursing care coordination as a distinct, billable service, CMS is strengthening support for advanced primary care delivery models—especially in underserved and rural settings.
These policy changes help ensure that the full range of resources required to care for patients, particularly those with chronic or complex needs, are appropriately valued and supported within Medicare.
CMS is also asking for feedback on this proposed alignment process for designating care coordination services annually.
If accepted in the final rule, the “List of Designated Care Management Services” would be updated and published with each year's PFS rule. Additionally, HCPCS code updates and manual revisions for accurate billing and supervision compliance would be carried out each year.
Share your opinion: CMS Request for Information
In addition to outlining their proposed changes for next year, CMS invites input via a Request For Information (RFI). The following topics from the RFI stand out to us, and you may wish to provide feedback on them.
Chronic disease prevention and management
CMS is soliciting input on enhancing Medicare's approach to chronic disease, including:
- Service coding gaps
- Use of wearable tech
- Social isolation interventions
- Support for an intensive lifestyle program
- Support for a medically tailored meal program
CMS is also seeking comment on other important topics, including:
- Covering FDA-cleared digital therapeutics
- Revising Annual Wellness Visit components
- Adding services, such as motivational interviewing and health coaching under general supervision
60-day comment period: Let your voice be heard
Healthcare professionals and the general public have until September 12, 2025, to submit comments (refer to file code CMS-1832-P) before this proposal is finalized.
This article only details the most relevant proposed changes to the 2026 Physician Fee Schedule that affect Medicare care management and our clients’ interests.
You can explore the full proposal in depth through CMS’s initial announcement or the full proposed rule on the Federal Register.
Register for ThoroughCare's 2026 proposal webinar
