decisionhealth Newsletters, Part B News - 2025 Issue 7 (July)
CMS wants to add OPPS to the PFS calculation mix for specific codes
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Article Overview
This article covers a CMS proposal in the 2026 Medicare physician fee schedule that would use hospital outpatient prospective payment system data in physician payment calculations for selected services. It is relevant to coders, reimbursement staff, and revenue cycle professionals tracking how Medicare may update practice expense valuation for remote monitoring and radiation treatment services. The article discusses the broader rationale CMS gives for using outpatient hospital cost data, the service categories affected, and the proposed payment-setting approach.
Why This Topic Matters
The proposal could affect valuation and reimbursement policy for several service families under the Medicare physician fee schedule, especially in areas where CMS is comparing hospital outpatient and physician fee schedule data sources. Readers following Medicare policy changes will want to understand which code groups are implicated and how CMS frames the methodology shift.
Article Sections
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Physician payments
Overview of the proposed Medicare physician fee schedule payment methodology change and the service categories it affects. The section introduces CMS’s stated rationale for using hospital outpatient data in practice expense valuation.
What You Will Learn
- The scope of CMS’s proposed payment methodology update
- Which broad service categories are affected by the proposal
- How CMS describes the use of hospital outpatient data in payment setting
- Why the proposal may matter for Medicare physician fee schedule valuation
Who Should Read This
- Medical coders
- Coding managers
- Reimbursement specialists
- Revenue cycle professionals
- Practice administrators
- Healthcare consultants
Codes Discussed
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