On Sept. 12, the College’s Advocacy Council submitted formal comments to CMS on the 2026 Medicare Physician Fee Schedule proposed rule. In this article, we break down our top concerns and key recommendations.
Medicare Physician Fee Schedule proposals:
- Physician reimbursement: The Advocacy Council supported CMS’s two proposed conversion factors for 2026, which include an increase of 3.83% for Alternative Payment Model Participants and 3.32% for all other items and services. We urged CMS to work with Congress to advance a long-term solution to this annual reimbursement issue.
- Practice expense (PE) value of CPT Code 95165: The Advocacy Council supported CMS’s increase to the direct cost input for CPT code 95165 (allergen immunotherapy antigens) from $8.96 to $13.00, a 45% increase. However, we provided data to show that this CPT code continues to be undervalued, and we requested that CMS further increase CPT code 95165’s direct cost input accordingly.
- PE methodology: The Advocacy Council supported CMS’s decision to refrain from utilizing the PE data in the AMA’s 2023-2024 Physician Practice Information Survey (PPI Survey). We thanked CMS for recognizing ACAAI’s concerns that the survey data does not reflect the true PE for allergy practices.
- Direct supervision: The Advocacy Council supported CMS’s proposal to permanently adopt flexibilities that would permit physicians to be immediately available through virtual real-time audio/visual technology for supervision purposes.
- Efficiency adjustment: The Advocacy Council opposed CMS’s proposed efficiency adjustment which reflects a 2.5% decrease to the Work Relative Value Unit (RVU) and corresponding intraservice portion of physician time of non-time-based services. We emphasized that CMS’s estimations do not reflect increases in care complexity, patient acuity, staff salaries, and other costs and urged the agency to not finalize this proposal.
- E/M visit complexity add-on: The Advocacy Council requested that CMS revisit its estimate of utilization for E/M visit complexity add-on code G2211. We described how CMS’s overestimation of the use of this code has negatively impacted the conversion factor due to budget neutrality adjustment requirements. We also provided recommendations to the agency to correct this error for future payment years.
- Telehealth:
- The Advocacy Council requested that CMS work with Congress to pass legislation to permanently extend Medicare telehealth flexibilities implemented during the COVID-19 pandemic.
- We also expressed concern about any potential requirement for physicians who provide telehealth services to report their home address.
- Geographic Practice Cost Index (GPCI) floor: The Advocacy Council alerted CMS that the GPCI floor, which adjusts physician payment to reflect the relative costs of goods and services across different areas of the country, is set to expire on Sept. 30, 2025. We urged CMS to work with Congress to ensure the GPCI floor is renewed.
- Request for information (RFI) on prevention and management of chronic disease: The Advocacy Council highlighted the prevalence of respiratory allergies and the effectiveness of allergen immunotherapy as a treatment. We reiterated to CMS that its current definition of a “dose” for purposes of CPT code 95165 does not reflect clinical standards of care and urged the agency to adopt the AMA CPT codebook’s “dose” definition.
MIPS Proposals
- Performance threshold: The Advocacy Council supported CMS’s decision to maintain the performance threshold at 75 points for the 2026 performance year.
- Quality measures: The Advocacy Council opposed CMS’s efforts to reduce the quality measures and urged CMS to retain sufficient quality measures in the program to preserve reporting flexibility and ensure accurate quality assessment.
- New promoting interoperability measure suppression policy: The Advocacy Council supported a new flexibility proposed by CMS that would give the agency the ability not to score new performance measures promoting interoperability in an applicable performance period in certain circumstances. We emphasized that this proposal offers needed flexibility to ensure that assessment of performance under the MIPS program is fair.
- Cost performance category
- The Advocacy Council supported an update to the attribution policy for the Total Per Capita Cost (TPCC) measure that would help prevent misattribution.
- The Advocacy Council supported a proposal that would provide an informational-only feedback period for new cost measures. Clinicians’ scores on new cost measures will not count toward their final score for the first two years the new cost measure is available, ensuring clinicians can gain familiarity with new measures before the measures impact their performance.
- Timely feedback: The Advocacy Council requested that CMS provide physicians with more timely access to feedback on their performance on MIPS measures and expressed disappointment with the agency’s failure to address data access issues.
MIPS Value Pathway proposals
- Sunsetting the traditional MIPS program: The Advocacy Council opposed CMS’s plan to sunset the traditional MIPS program by the 2029 performance period and recommended that CMS maintain MVP participation as voluntary for the foreseeable future.
- MVP development: The Advocacy Council requested that the agency ensure relevant MVP options for allergists by either developing a separate MVP for the practice of allergy or including quality measures that are clinically meaningful to allergists in the Pulmonology Care MVP.
- Core elements RFI: The Advocacy Council opposed CMS’s proposal to require the reporting of certain quality measures within each MVP (referred to as core elements). We reiterated that this proposal was premature given that allergists do not have meaningful reporting options in the MVP program.
- RFI on procedural codes for MVP assignment: The Advocacy Council opposed the forced assignment of clinicians to an MVP by using procedural code data. We stated that this approach would risk assigning allergists to inappropriate MVPs given the lack of MVPs currently available to allergists. Practitioners should have the ability to determine which MVP is appropriate for their practice.
- Ambulatory specialty model: The Advocacy Council opposed CMS’s proposal to create a new mandatory alternative payment model that measures clinicians against their peers on a defined set of episode-based cost measures. While the model focuses on clinicians that treat heart failure and low back pain and not allergists, we expressed concern with potential expansion to other specialties and the disproportionate negative impact the model will have on small and rural practices.
The final rule is typically published in early November. We will monitor and notify members of all issues related to allergists and their practices.
The Advocacy Council – ADVOCATING THE ALLERGISTS AND THEIR PATIENTS.
