CMS’ final 2026 Medicare physician fee schedule is set to take effect Jan. 1, posing valuation risk for complex spine surgery, according to the International Society for the Advancement of Spine Surgery.
Five things to know:
1. Beginning in 2026, there will be two separate conversion factors: one for qualifying alternative payment model participants and one for physicians and practitioners who are not QPs. The conversion factors are $33.5675 for APM participants and $33.4009 for others, representing a 3.77% and 3.26% increase, respectively, compared to 2025. However, these small increases are offset by structural cuts affecting procedural services, according to the ISASS.
There’s also a new practice expense allocation model that lowers reimbursement for facility-based surgical specialties and raises non-facility rates.
2. For spine surgeons, a valuation methodology shift could pose obstacles to complex care. In the past, CMS used AMA survey data to estimate the valuation of CPT codes, but now the agency is shifting away from that.
3. CMS’ 2026 rule will implement a 2.5% reduction to the work relative value unit and intraservice physician time for all non-time-based services. This is something ISASS leaders expressed worry about in a Dec. 9 policy update email.
“The CY 2026 PFS final rule represents another structural shift away from procedural, facility-based care, with direct repercussions for the valuation of spine surgery,” ISASS said in the statement. “Of greatest concern to spine surgeons is the 2.5% efficiency adjustment, which breaks from the RUC’s statutory logic (Time × Intensity) and reduces surgical valuation without any evidence of increased efficiency in complex spine surgery.”
4. CMS finalized a new method for allocating indirect Practice Expense RVUs based on site of service, shifting reimbursement away from OR-dependent specialties like spine surgery. The agency noted a decline in private practice and increased hospital employment, concluding that allocating indirect costs equally across facility and non-facility settings no longer reflects current practice patterns.
5. CMS didn’t finalize any binding reforms related to Medicare Advantage prior authorization. MA plans may continue practices such as retroactive coverage reversals, non-evidence-based denials, delays in necessary spine surgery, and other administrative policies different from traditional Medicare.
ISASS’ email reaffirmed advocacy for protection of the traditional valuation methodology, equity for facility-based surgical specialties, relief from MA prior authorization and accurate representation of surgical work and resource utilization.
