New data source and other changes to CMS’ proposed 2026 Physician Fee Schedule

The time for Centers for Medicare & Medicaid Services (CMS) payment rate review has arrived, and the proposed fee schedule comes with possible pros and cons for doctors of optometry. 

The valuation of procedural codes has long been based on insights provided by the American Medical Association’s Relative Value Scale Update Committee (RUC) survey. But as the New York Times recently reported, the AMA’s assessment has come under fire from CMS.  

Here are several of the changes the CMS proposed rule will bring in January 2026: 

Value adjustment 

For certain codes instead of RUC data, CMS plans to use an ‘efficiency adjustment’ to adjust the value of the procedure. Eye exam codes are not currently listed, but some codes reported by doctors of optometry, including biometry and corneal hysteresis, are. This adjustment would use the sum of the last five years of the Medicare Economic Index to set rates.  

Telehealth codification 

Telehealth is here to stay. CMS is removing the ‘provisional’ designation, creating a permanent listing for appropriate telehealth services, including eye exams. While CMS reserves the right to remove services from the list after internal review or feedback, currently this creates a permanent avenue for eye services via telehealth.  

CMS notes that this designation doesn’t mean telehealth is appropriate in all cases; it will be up to the provider to determine whether telehealth is the best medium for care.  

Facility vs. non-facility rates differ 

Another upcoming change involves providers based in a facility versus a non-facility. To acknowledge indirect costs incurred by those in hospitals, ambulatory surgical facilities and skilled nursing facilities, optometrists who practice in an standalone office may receive a 3% increase in practice expense, while those in facilities could face a 13% decrease.  

Conversion factor updates 

Providers considered qualifying participants (QPs) and who accept advanced alternative payment (AAP) models under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will receive higher conversion factors and slightly higher Medicare payments than non-QP physicians, starting in 2026.  

Qualifying participants in advanced alternative payment models will receive a slightly higher conversion factor ($33.5875) compared to traditional fee-for-service providers ($33.4209). Both figures represent increases from the current $32.3465, driven by permanent updates, a one-time 2.5% adjustment from recent legislation, and budget neutrality modifications. 

MIPS remains stable 

The Merit-based Incentive Payment System (MIPS) threshold remains unchanged at 75 points to avoid penalties of up to 9% through the 2028 performance year and 2030 payment year, providing stability in quality reporting requirements. 

Further input requested 

 In addition to the policy proposals noted above,  CMS is also still seeking information on several subjects, including:  

• Reimbursement for AI devices and SaaS – Should CMS pay for these tools, and what alternative pricing strategies should they use?  
• How to better care for patients with chronic conditions – How can CMS better support prevention and management, including self-management?  
• Using FHIR for quality measure reporting.  

AOA will be fully active in our advocacy on behalf of optometry and our direct engagement of CMS in response to these proposals. Want to make your voice heard in response to these policy proposals? Contact AOA President Jacquie M. Bowen, O.D., at president@aoa.org.