Medicare PFS 2026 proposed rule

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BobbyHeenan

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Bridge just posted this. Looks like they are eliminating CBCT (77014) or image guidance charges and bundling into new delivery codes.

Looks like maybe all igrt on pro side is 77387, 0.7 wRVUs. I *think* the 77014 code used to be 0.85.

I haven’t seen any Astro commentary. I think this just came out today.

Dropbox
 
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My initial reads of the proposed rule:

1) Freestanding rad onc centers are going to be decimated. They're going to take a hit on IMRT moving from G-code to 77xxx and will no longer be able to bill IGRT w/ IMRT like they've been able to. This might result in ~30% or more drops in revenue at freestanding centers. Well, not might... it will.
2) Superficial/orthovoltage users are going to see ~50-90% drops in revenue.
3) On the whole, hospital centers should see no huge changes.

But, I could be reading it wrong. But, I don't think I am.

If this all goes through, every rad onc in America (even if they're affected by the rule or not) should no longer be an ASTRO member just out of principle.
 
IMG_6501.jpeg
 
HolySmokes said:
Is all IGRT covered under the same code now? Port films, kv, and CBCT?
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That’s the way im interpreting per the bridge document…. All bundled on tech side and 77387 on pro side remains.

I haven’t seen other clarification though .
 
77014 being deleted. Used to carry a 0.85 wRVU
Replaced by 77387 with a physician component of 0.7 wRVU

12% hit to the most valuable professional code for rad oncs
Given that this code is about 25% of our RVUs, this should result in about a 3% decrease in wRVUs to employed rad oncs.
Rough back of the napkin math results in an average $20k paycut to employed rad oncs. For reference, there has been 33% inflation from 2016.


"We are proposing the RUC-recommended work RVU of 0.70 for the single code in the family that has a physician work component, CPT code 77387."

Based on what, exactly? Why the decrease in the value of the work by 12%? Explain.

I am unclear about G6002. If you can no longer bill G6002 (0.39 wRVU) and instead bill 77387 for both kVs and CBCTs, this could be a wash as payments for reading kVs and cone beams are now equal apparently?

Also... The proposed conversion factor for Qualifying APM participants is $33.5875, while the proposed factor for non-APM participants is $33.4209. These amounts represent increases of 3.8% and 3.3%, respectively, compared to the 2025 conversion factor.

But, it looks like the wRVU values of many professional codes are being cut by about 3% (77301, 77295, 77334, etc).

What is 1 divided by zero? How much does an "IMRT accelerator" and a vault cost? Some things are just unknowable, it seems.
 
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There will be a physician payment for port films now?

Currently:

Cone beam review (77014): 0.85 wRVU
kV review (G6002): 0.39 wRVU
Port films (77417): 0.00 wRVU (the physician port film review component considered part of on treatment management 77427).

Proposed 77387 for all image guidance: 0.70 wRVU

Good day to be a (employed) breast rad onc if that's true.
 
Looks like G6002 (kv) and 77417 (ports) codes are still around, so are those just the technical codes and the professional codes for them are now 77387?
 
alwaysbeIMRTing said:
There will be a physician payment for port films now?

Currently:

Cone beam review (77014): 0.85 wRVU
kV review (G6002): 0.39 wRVU
Port films (77417): 0.00 wRVU (the physician port film review component considered part of on treatment management 77427).

Proposed 77387 for all image guidance: 0.70 wRVU

Good day to be a (employed) breast rad onc if that's true.
Click to expand...
Good question.

I guess it will depend upon if you consider weekly port films as “image guidance” or whatever updated description you’re getting for 77387.

I’m skeptical you’d get paid for that on say a R sided breast. *maybe* a 1x/week charge at best.
 
Does anybody have the data source Jordan is getting the new work RVU values from? For instance, 77301 decreasing from 7.99 to 7.79?
When's the last time the work RVU values of the professional codes were mucked with? These have been set for well over a decade and this is the first I am hearing of this.
 
Mods - can we merge this thread with the other thread? Important discussions going on here.
 
TheWallnerus said:
With the new codes I do think there is going to be a significant drop for everyone. (But again more so for freestanding.) Which means ROCR proposed case rates will never pass CBO muster for being cost neutral.
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It seems like doctors across the board in all specialties are getting completely shafted. With AI greatly simplifying our workflows in the future, CMS is just going to say that the robot is doing most of the work now and those wRVUs for plan generation are just going to be chipped away at every year until an IMRT plan pays the same as a blood draw.

CMS is proposing to apply an “efficiency adjustment” to the intra-service times and work relative value units of nearly all non-time-based codes in the fee schedule. It plans to adjust these figures in the future, when physicians produce “gains in efficiency over time.” For instance, imaging exams or interventional procedures that might be delivered more quickly, due to new technologies allowing for quicker care delivery. These updates would periodically apply to virtually all codes, except those tied to time, such as evaluation and management, behavioral health and other services on the Medicare telehealth list.

2026 Medicare Physician Fee Schedule proposes 3.6% pay bump, permanent remote imaging supervision
 
alwaysbeIMRTing said:
It seems like doctors across the board in all specialties are getting completely shafted. With AI greatly simplifying our workflows in the future, CMS is just going to say that the robot is doing most of the work now and those wRVUs for plan generation are just going to be chipped away at every year until an IMRT plan pays the same as a blood draw.

CMS is proposing to apply an “efficiency adjustment” to the intra-service times and work relative value units of nearly all non-time-based codes in the fee schedule. It plans to adjust these figures in the future, when physicians produce “gains in efficiency over time.” For instance, imaging exams or interventional procedures that might be delivered more quickly, due to new technologies allowing for quicker care delivery. These updates would periodically apply to virtually all codes, except those tied to time, such as evaluation and management, behavioral health and other services on the Medicare telehealth list.

2026 Medicare Physician Fee Schedule proposes 3.6% pay bump, permanent remote imaging supervision
Click to expand...

It’s basically a way to pay for “time based specialties” like PC. So they shaft the procedural and high expense specialties to pay for it which they justify with murky terms like efficiency gains…which apparently have not happened in PC
 
thesauce said:
Isn’t the much bigger issue the shift in the indirect practice expense (PE) methodology to match hospital OPPS data? That’s a 25% technical hit.
Click to expand...
Matching OPPS is what’s going to really hurt freestanding in having to move from G code to 77xxx for IMRT.
 
TheWallnerus said:
Which means ROCR proposed case rates will never pass CBO muster for being cost neutral.
Click to expand...
Seems to me ROCR was an attempted urgent "end around" initiative to get in front of anticipated cuts. (Not terribly well supported by specialty due to ASTRO elitism). I believe a new rule/fee schedule only becomes the cost comparator for cost neutrality once implemented.

Agree that ROCR is dead.
 
thesauce said:
Isn’t the much bigger issue the shift in the indirect practice expense (PE) methodology to match hospital OPPS data? That’s a 25% technical hit.
Click to expand...

If I understand their rationale correctly, they are basically calling the freestanding centers liars in respect to their operating costs.

Site-of-Service Payment Differential: CMS continues to refine its site-of-service policies, particularly the differential between payments for services provided in freestanding (non-facility) settings versus hospital outpatient departments (HOPDs). Freestanding radiation centers typically receive higher payments under the PFS than HOPDs under the Outpatient Prospective Payment System (OPPS) for similar services due to differences in cost structures. However, CMS proposes adjustments to align payments more closely across settings, citing data showing that the cost of delivering radiation therapy in freestanding centers may not justify the higher payment rates. This is part of a broader effort to reduce disparities and ensure equitable reimbursement across care settings.

Wouldn't protons be the low hanging fruit if the goal was maintaining budget neutrality? They apparently "welcome comments on this topic." (establishing RVUs for proton delivery).

Not the site-neutral payments everyone was advocating for?
 
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TheWallnerus said:
3) On the whole, hospital centers should see no huge changes.
Click to expand...

Well from my read the APC 5623 level 3 radiation services (IMRT codes 77385 and 77386) are now being replaced by 77412, which was a 5622 level 2 code that pays 2.2x less. However, it appears that 77412 is now being bumped up to 5623.

However, the IMRT codes were all level 3 before.

So some (maybe most?) IMRT treatments well be classified in 5622 because they will have to be billed as 77407 (Radiation treatment delivery; Level 2, single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed).

So, unless I'm reading this wrong, hospitals are going to be getting paid 2.2x less for routine prostate, head and neck, lung, etc. IMRT. Wouldn't this be a huge change? Unless there is a massive change to the valuation differential between 5622 and 5623, which is yet to be determined. And these APC codes will inform payments to freestanding facilities.

77412: Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) OR a single isocenter photon therapy (eg, 3D or IMRT) with active motion management, OR total skin electrons, OR mixed electron/photon field(s), including imaging guidance, when performed
 
alwaysbeIMRTing said:
Well from my read the APC 5623 level 3 radiation services (IMRT codes 77385 and 77386) are now being replaced by 77412, which was a 5622 level 2 code that pays 2.2x less. However, it appears that 77412 is now being bumped up to 5623.

However, the IMRT codes were all level 3 before.

So some (maybe most?) IMRT treatments well be classified in 5622 because they will have to be billed as 77407 (Radiation treatment delivery; Level 2, single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed).

So, unless I'm reading this wrong, hospitals are going to be getting paid 2.2x less for routine prostate, head and neck, lung, etc. IMRT. Wouldn't this be a huge change? Unless there is a massive change to the valuation differential between 5622 and 5623, which is yet to be determined. And these APC codes will inform payments to freestanding facilities.

77412: Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) OR a single isocenter photon therapy (eg, 3D or IMRT) with active motion management, OR total skin electrons, OR mixed electron/photon field(s), including imaging guidance, when performed
Click to expand...

...I think we may see a lot more gated lung treatments.

If you do a 5 fraction apbi DIBH (which I do quite a bit for L sided cases) I suspect that too would be 77412 , correct?
 
Or multiple isocenters.

I mean, they appear to have redefined 77407 and dumped routine IMRT and 3D treatments into it. (For reference, this would currently result in a decrease in the HOPPS payment from $578 to $263).

OSMS for everybody? I worked at a center that did that. I thought they were stupid (I still think they are).

What is the reimbursement change that is being proposed? - Vision RT

Here is an excerpt from the proposed new coding: 77402 77407 77412 Level 1 (eg, single electron field, multiple electron fields, or 2D photons). Including imaging guidance, when performed Level 2 single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed Level 3...
visionrt.com visionrt.com
 
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alwaysbeIMRTing said:
Or multiple isocenters.

I mean, they appear to have redefined 77407 and dumped routine IMRT and 3D treatments into it. (For reference, this would currently result in a decrease in the HOPPS payment from $578 to $263).

OSMS for everybody? I worked at a center that did that. I thought they were stupid (I still think they are).

What is the reimbursement change that is being proposed? - Vision RT

Here is an excerpt from the proposed new coding: 77402 77407 77412 Level 1 (eg, single electron field, multiple electron fields, or 2D photons). Including imaging guidance, when performed Level 2 single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed Level 3...
visionrt.com visionrt.com
Click to expand...

Good catch.

Though I bet medicare LCD will start paring down which ICD10's will qualify for the 77412 and which ones won't....suspect say R sided breast or prostate may not fall in there.

This is going to be a wild-west of billing for a few years.

The difference per fraction for 77407 vs. 77412 is MASSIVE.
$216.23 vs. $ 482.93

Assuming surface guidance buys you 77412....you better put your order in now.
 
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TheWallnerus said:
Def won't buy you 77412. Buys you 77X09. DO NOT PLACE ORDER.
Click to expand...

VisionRT is basically advertising it will with that link posted above. Now whether that's correct....

1752598375216.png


What is the reimbursement change that is being proposed? - Vision RT

Here is an excerpt from the proposed new coding: 77402 77407 77412 Level 1 (eg, single electron field, multiple electron fields, or 2D photons). Including imaging guidance, when performed Level 2 single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed Level 3...
visionrt.com visionrt.com
 
OSMS is used to monitor motion during treatment. We would literally shine it down on head and necks in a mask. Because the physicist thought that was the only safe way to deliver treatment. We didn't get along. I'm sure prior auth would blow it up anyway. But hey, the VA jobs will all fill with fierce competition now. Imagine being a new single-specialty PP partnership-track doc in year 1 on an associate salary right now. Ouch.
 
alwaysbeIMRTing said:
OSMS is used to monitor motion during treatment. We would literally shine it down on head and necks in a mask. Because the physicist thought that was the only safe way to deliver treatment. We didn't get along. I'm sure prior auth would blow it up anyway. But hey, the VA jobs will all fill with fierce competition now. Imagine being a new single-specialty PP partnership-track doc in year 1 on an associate salary right now. Ouch.
Click to expand...

We have vision RT on some of our machines in our network. It is used at our discretion. SOme therapsists love it and feel comfortable with it for a ton of cases. On the doc side I have liked it for DIBH breast especially adn complex sarcoma set ups. We really only bill it for some DIBH cases where we aren't billing CBCT's.

Not sure if the hospital is billing it or not on the technical side.

We turn it on for lots of cases though (even head and necks) but don't bill for it I don't think on the technical side, but I'm not sure. I just know the pro billing and we definitely wouldn't bill for it on a CBCT case (where we're billing 77014-26) instead.
 
alwaysbeIMRTing said:
Does anybody have the data source Jordan is getting the new work RVU values from? For instance, 77301 decreasing from 7.99 to 7.79?
When's the last time the work RVU values of the professional codes were mucked with? These have been set for well over a decade and this is the first I am hearing of this.
Click to expand...

CMS-1832-P | CMS

The proposed rule with comment went on display at the Office of the Federal Register’s Public Inspection Desk on July 14, 2025, and will be available until the regulation is published on July 16, 2025. The comment period will close on September 12, 2025. See CMS-1832-P in the “Related Links”...
www.cms.gov www.cms.gov

Under "CY 2026 PFS Proposed Rule Codes Subject to Efficiency Adjustment"

Basically every RT code gets a 3% haircut immediately (even the CBCT code, which was already getting 12% chopped off!)
 
HolySmokes said:

CMS-1832-P | CMS

The proposed rule with comment went on display at the Office of the Federal Register’s Public Inspection Desk on July 14, 2025, and will be available until the regulation is published on July 16, 2025. The comment period will close on September 12, 2025. See CMS-1832-P in the “Related Links”...
www.cms.gov www.cms.gov

Under "CY 2026 PFS Proposed Rule Codes Subject to Efficiency Adjustment"

Basically every RT code gets a 3% haircut immediately (even the CBCT code, which was already getting 12% chopped off!)
Click to expand...

It’s so insane. Literally year in year out cuts. There is no magic solution.
 
HolySmokes said:
Basically every RT code gets a 3% haircut immediately (even the CBCT code, which was already getting 12% chopped off!)
Click to expand...

So ASTRO blew all their energy trying to cram down case rates and supervision mandates instead of protecting pro codes from getting devalued in terms of physician effort? Or somehow letting IMRT delivery slide down into a treatment code that is almost never billed now because what it covers is so rudimentary? Unbelievable.

So they have proposed adding a PC component to 77387 with 0.70 wRVU and they have already proposed an efficiency adjustment cut to it down to 0.68 wRVU. How does that work?
 
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BobbyHeenan said:
We have vision RT on some of our machines in our network. It is used at our discretion. SOme therapsists love it and feel comfortable with it for a ton of cases. On the doc side I have liked it for DIBH breast especially adn complex sarcoma set ups. We really only bill it for some DIBH cases where we aren't billing CBCT's.

Not sure if the hospital is billing it or not on the technical side.

We turn it on for lots of cases though (even head and necks) but don't bill for it I don't think on the technical side, but I'm not sure. I just know the pro billing and we definitely wouldn't bill for it on a CBCT case (where we're billing 77014-26) instead.
Click to expand...

We use it for all patients. I am more of a believer now than I was before when I was at other centers that used it selectively or not at all. I also have DoseRT at one of our sites, the cherenkov thing.

I think it offers some niche benefits and it is nice for the therapists to have a single platform across the whole treatment workflow. It is really hard to make arguments it is clinically better than the alternatives.

Like you we do not really bill for it except we are now trying it on fractions where there is no other imaging.

I did locums once for a center that did bill it. They printed out a report and made me hand sign them all in ink at the end of the day. I suspect they did this because free standing centers can bill both. Looks like that will no longer be true in 2026.
 
alwaysbeIMRTing said:
I would say a wild west of rapid practice insolvency. 77407 is hardly ever billed now. It's either 77385/6 or 77412.

Here's a BCBS hospital paytable showing $1030.72 for 77386, $515.36 for 77385, and $255.88 for 77407: https://www.bcbstx.com/docs/provide.../2020-hosp-nonsurg-radtherapy-july2022-v1.pdf

G6015 is $362.55 (freestanding IMRT billing) FWIW.
Click to expand...

...and if you can swap your G6015 with a 77412 (again, assuming you use OSMS), then you will actually come out ahead I think.
 
For RVU-based employed doctors or independent groups with RVU contracts, this is a real kick in the teeth. Since the work RVU values of codes have been stable for a long time, conversion factor and MPFS cuts really haven't affected you. In this case, there a 3% CF increase you won't see but a 3% haircut to the RVUs nearly all your professional codes (except 77427, so there's something).

Yeah, I agree the hit going from G6015 to 77407 seems less than going from 77335 to 77407. I guess the point is the freestanding centers are less able to absorb the impact? Is the bigger issue the loss of billing 77014 globally at freestanding? What does a 77014 pay out on average in the freestanding setting now when billing G6015 for delivery? It's something like $40 I think when billing -26 on the pro side.
 
Even with 77427 exempt, based on my RVUs for the first six months of this year and how they'd shake out with the new cuts it's about a 4.5% decrease for the same volume. When big changes to RVUs like this happen in the past my hospital has renegotiated the $/RVU higher to try to offset some of the loss for physicians but if they are about to take big hits on technical reimbursement for treatment I wonder if they'll feel quite so generous.
 
HolySmokes said:
Even with 77427 exempt, based on my RVUs for the first six months of this year and how they'd shake out with the new cuts it's about a 4.5% decrease for the same volume. When big changes to RVUs like this happen in the past my hospital has renegotiated the $/RVU higher to try to offset some of the loss for physicians but if they are about to take big hits on technical reimbursement for treatment I wonder if they'll feel quite so generous.
Click to expand...

Hospitals are taking from all sides this year as well. I’m doubtful esp at my shop which is mostly Medicaid.
 
alwaysbeIMRTing said:
For RVU-based employed doctors or independent groups with RVU contracts, this is a real kick in the teeth. Since the work RVU values of codes have been stable for a long time, conversion factor and MPFS cuts really haven't affected you. In this case, there a 3% CF increase you won't see but a 3% haircut to the RVUs nearly all your professional codes (except 77427, so there's something).

Yeah, I agree the hit going from G6015 to 77407 seems less than going from 77335 to 77407. I guess the point is the freestanding centers are less able to absorb the impact? Is the bigger issue the loss of billing 77014 globally at freestanding? What does a 77014 pay out on average in the freestanding setting now when billing G6015 for delivery? It's something like $40 I think when billing -26 on the pro side.
Click to expand...
which is now about 80%+ of radiation oncologists.
 
alwaysbeIMRTing said:
For RVU-based employed doctors or independent groups with RVU contracts, this is a real kick in the teeth. Since the work RVU values of codes have been stable for a long time, conversion factor and MPFS cuts really haven't affected you. In this case, there a 3% CF increase you won't see but a 3% haircut to the RVUs nearly all your professional codes (except 77427, so there's something).

Yeah, I agree the hit going from G6015 to 77407 seems less than going from 77335 to 77407. I guess the point is the freestanding centers are less able to absorb the impact? Is the bigger issue the loss of billing 77014 globally at freestanding? What does a 77014 pay out on average in the freestanding setting now when billing G6015 for delivery? It's something like $40 I think when billing -26 on the pro side.
Click to expand...


HolySmokes said:
Even with 77427 exempt, based on my RVUs for the first six months of this year and how they'd shake out with the new cuts it's about a 4.5% decrease for the same volume. When big changes to RVUs like this happen in the past my hospital has renegotiated the $/RVU higher to try to offset some of the loss for physicians but if they are about to take big hits on technical reimbursement for treatment I wonder if they'll feel quite so generous.
Click to expand...

I haven't checked the math, but Bridge is sending out emails doing pro formas and presuming you're doing a bunch of 77412, I am not convinced there will be any cut at all and in fact may be a boost in technical/global revenue.

I do think though on the pro side you're looking at about a 2-5% cut for various reasons.
 
HolySmokes said:
When big changes to RVUs like this happen in the past my hospital has renegotiated the $/RVU higher to try to offset some of the loss for physicians but if they are about to take big hits on technical reimbursement for treatment I wonder if they'll feel quite so generous.
Click to expand...
Every non-salaried employed rad onc in the country will need to renegotiate his/her RVU rates. Sucks to be in a saturated area as your leverage will be zero. On the other hand, changes to the tax code might preferentially benefit 1099 locums doctors with S-corporations who don't care about RVUs anyway.
 
Looks like Bridge is adjusting numbers.

This looks rougher than what I had seen previously. They were previously suggesting the 77412 at closer to $400…this has it down to $275.



 
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GapCalc said:
I don't mean to sound like a jerk but... are going to to trust Jordan on this one? Any other credible sources evaluating changes?
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Ha - yeah I would DEFINITELY recommend everyone look at primary sources and wait and see what (ugh) ASTRO is saying.

Especially given already there have been some pro forma changes in the last day.

But I think taking their info (or insert Ron or some other tangential consultant), filtering it out, etc....helps get a grasp of the climate.

I think the collective input of X/Twitter, SDN, and others will get you a good grasp of posssible options. I do think it is helpful that Bridge seems to be "first" in trying to get out info though. ...just know it may not be set in stone or fully credible.
 
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