Breaking Down the 2026 Proposed Rule

Nothing signals the dog days of summer quite like the release of CMS’s proposed rule. Sure, there are other markers, like cookouts, pool parties, or MLB’s All-Star Game, but real ones know that you’re well and truly in the dead of summer when you’re deep into a 2,000-page document. (Or a little less this year, thankfully.)  Of course, you’d rather be doing any of those fun summer activities, so we went ahead and read through the entire 2026 proposed rule to pull out all the relevant facts you need to prepare for, should they get finalized in November. It’s our way of showing love, aided in no small part that it’s too hot for us Phoenicians to go out anyway. 

Without further ado, let’s get into it.  

There are now two conversion factors.

We’ll start with what you’re all here to see: the 2026 conversion factor. There’s a big change here, as 2026 marks the introduction of two separate conversion factors. The first is the qualifying APM conversion factor, which is for providers participating in alternative payment models (APMs). The second is the nonqualifying APM conversion factor, which applies to providers who aren’t qualified under APMs. 

The proposed rule states on page 1188 that "(w)e estimate the CY 2026 PFS qualifying APMCF to be 33.5875 which reflects a 0.55 percent positive budget neutrality adjustment required under section 1848(c)(2)(B)(ii)(II) of the Act and the 0.75 percent update adjustment factor specified under section 1848(d)(20) of the Act. We estimate the CY 2026 PFS nonqualifying APM CF to be 33.4209 which reflects a 0.55 percent positive budget neutrality adjustment required under section 1848(c)(2)(B)(ii)(II) of the Act and the 0.25 percent update adjustment factor specified under section 1848(d)(20) of the Act." Clearly, this is part of CMS’s ongoing push to drive providers toward enrolling in MIPS or MVPs. 

Telehealth gets out of limbo.

If you’ve followed the past several proposed/final rules, you know that telehealth has long lingered as the service that exists for now but may well disappear when the next rule changes are published. It seems CMS has thought better of the back-and-forth: 

“We are proposing, beginning for the CY 2026 Medicare Telehealth Services List, to revise the 5-step review process for reviewing requests to the Medicare Telehealth Services List. Based on feedback from interested parties, we believe that we need to simplify our telehealth list review process by focusing our review on whether the service can be furnished using an interactive telecommunications system.” 

CMS goes on to state that, under this proposal, they would do away with the designations of provisional and permanent for telehealth services. All the services currently on the Medicare Telehealth Services List would be considered included on a permanent basis. If the proposal doesn’t go through, CMS will consider all of the currently provisional services before making decisions on which to include on the permanent list. However, rehab therapists still need congressional action to be included on the list of eligible providers for these services if they hope to remain past the current expiration date of September 30 for their temporary privileges.

RTM codes are getting some new additions. 

Given that remote therapeutic monitoring (RTM) remains relatively new, it’s no surprise to see continued changes as CMS tries to refine and improve. This year’s proposed rule sees the addition of three new RTM codes (although the document says four):

• 98XX4: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 2-15 days in a 30-day period 
• 98XX5: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 2-15 days in a 30-day period
• 98XX7: Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one real-time interactive communication with the patient or caregiver during the calendar month; first 10 minutes

For those of you who love to get into the weeds, CMS has set the work relvative value units (RVU) for 98XX7 at 0.61. Codes 98XX4 and 98XX6 is a practice expense (PE) only code. 

CMS also updated the descriptors for three existing codes to further specify the minimum days of data transmission for those codes, which had served as a point of confusion since their introduction:

• 98976: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 16-30 days in a 30-day period
• 98977: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 16-30 days in a 30-day period
• 98978: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 16-30 days in a 30-day period

Per CMS, “All of the codes in the RTM family are considered new technology (CPT codes 98975, 98XX4, 98976, 98XX5, 98977, 98XX7, 98XX7, 98980, and 98981) and will be placed on the New Technology list to be reviewed after 3 years of data are available (April 2030).”

MIPS and MVPs are undergoing minor changes. 

Let’s start with what’s not changing for MIPS, yet again: the performance threshold. In the proposed rule, CMS states that the threshold is slated to remain at 75 points for both the CY 2026 performance period/2028 MIPS payment year and the CY 2028 performance period/2030 MIPS payment year—while also making clear their intent to stay at that number for 2029 and 2030. The reasoning offered surrounds getting more providers into MIPS and collecting more data before making changes, but the takeaway for MIPS participants is that 75 remains the score to shoot for. 

MIPS

The PT/OT Specialty Set is adding the following measure:

• 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

CMS is also proposing the removal of the following measures for both the PT/OT Specialty Set and the SLP Specialty Set: 

• 487: Screening for Social Drivers of Health
• 498: Connection to Community Service Provider

MIPS Value Pathways

The MIPS Value Pathways (MVP) program is adding six new MVPs around the following topics—none of them tied to rehab therapy, unfortunately:

• Diagnostic Radiology 
• Interventional Radiology
• Neuropsychology
• Pathology
• Podiatry 
• Vascular Surgery

The Rehabilitative Support for Musculoskeletal Care MVP is undergoing a few updates as well:

Quality Measures

Additions

• Q134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
• Q182: Functional Outcome Assessment

Removal

• Q487: Screening for Social Drivers of Health

QCDR Measures

Modifications

The following measures had their denominators updated to remove “patients that are non-English speaking and translation services are unavailable”:

• MSK6: Patients Suffering From a Neck Injury who Improve Pain
• MSK7: Patients Suffering From an Upper Extremity Injury who Improve Pain
• MSK8: Patients Suffering From a Back Injury who Improve Pain
• MSK9: Patients Suffering From a Lower Extremity Injury who Improve Pain

Improvement Activities

Additions

• IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
• IA_BE_16: Evidence-based techniques to promote self-management into usual care
• IA_AHW_X: Chronic Care and Preventative Care Management for Empaneled Patients

Removals

• IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health, 
• IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
• IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B

CMS is looking to test new payment models—and PTs could be involved. 

One particularly interesting development from this year’s proposed rule is the announcement that CMS is looking to introduce and test an Ambulatory Specialty Model (ASM). The ASM would be a mandatory alternative payment model that would run from January 1, 2027, through the end of 2031. ASM would specifically be “focused on the care provided by select specialists to Medicare beneficiaries with the chronic conditions of heart failure and low back pain,” which does make it sound like PTs could be involved. (This easier-to-digest CMS factsheet also lists rehabilitation under the low back pain specialists.)  

As CMS notes:

“Under the model, clinicians would be required to report a select set of measures and activities clinically relevant to their specialty type and the chronic condition of interest. These measures and activities would assess quality, cost, interoperability, and care coordination practices, all of which are necessary for effective upstream chronic condition management. To incentivize improvements in quality and care coordination, CMS would assess the clinician’s performance on those measures and activities relative to their peers, who are also participants of the model and of a similar specialty type treating the same chronic condition.” 

The aforementioned factsheet also sheds some light on what type of providers might be participating:

“ASM would include specialists who frequently treat low back pain or heart failure, practice within selected core-based statistical areas or metropolitan divisions, and have historically treated at least 20 Original Medicare patients with heart failure or 20 Original Medicare patients with low back pain over a 12-month period. Physicians would be assessed individually, not at the practice level.”

If you’re interested in learning more about the proposed ASM, you can start reading here. It’s too early in the process to start planning for what ASM might mean for PT clinics, but it’s worth keeping an eye on moving forward.  

Make your voice heard. 

Another time-honored summer tradition, following soon after the release of the proposed rule, is the call to comment. Something you like? Something you don’t? It’s easy to register your opinion with CMS; we’ve even gone ahead and hyperlinked it for you here to save you the time of having to search. I’ll see you back here around Thanksgiving to see what’s survived the comment period and what we can expect for 2026.