Get a clear breakdown of the CMS 2026 Proposed Rule, including key updates, policy changes, payment adjustments, and what they mean for healthcare providers. Stay informed with this comprehensive, easy-to-understand guide.
Introduction
The Centers for Medicare & Medicaid Services (CMS) has released the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, introducing significant updates across behavioral health, remote monitoring, care management, and rural health billing. These changes aim to improve patient care coordination, align billing practices, and provide greater flexibility for healthcare providers.
Behavioral Health Integration in APCM – New Code
CMS proposes integrating Behavioral Health Integration (BHI) into Advanced Primary Care Management (APCM) through three new add-on G-codes. This allows providers to bill both APCM and BHI/Collaborative Care Model (CoCM) services for the same patient within the same month.
The three new codes include:
- GPCM1: First-month CoCM services (similar to 99492), covering 70 minutes of work
- GPCM2: Subsequent-month CoCM services (similar to 99493), covering 60 minutes
- GPCM3: General behavioral health care management (similar to 99484), requiring at least 20 minutes of clinical staff time
This integration ensures that behavioral health services complement existing codes while offering enhanced billing flexibility for comprehensive patient care.
Remote Patient Monitoring and Remote Therapeutic Monitoring Enhancements
The proposed rule introduces new RPM and RTM codes for monitoring periods of 2-15 days, while existing codes now apply to 16-30 days. This change ensures fair reimbursement for shorter monitoring periods and reflects real-world patient engagement patterns.
Key updates include:
- New codes for 2-15 days of data collection
- Existing codes designated for 16-30 days of monitoring
- More accurate reimbursement based on actual monitoring duration
- Reduced administrative complexity for partial-month billing
These enhancements support broader adoption of remote monitoring technologies and provide appropriate compensation for varying levels of patient engagement.
Remote Patient Monitoring and Remote Therapeutic Monitoring Enhancements
The proposed rule introduces new RPM and RTM codes for monitoring periods of 2-15 days, while existing codes now apply to 16-30 days. This change ensures fair reimbursement for shorter monitoring periods and reflects real-world patient engagement patterns.
Key updates include:
- New codes for 2-15 days of data collection
- Existing codes designated for 16-30 days of monitoring
- More accurate reimbursement based on actual monitoring duration
- Reduced administrative complexity for partial-month billing
These enhancements support broader adoption of remote monitoring technologies and provide appropriate compensation for varying levels of patient engagement.
Enhanced Time Management in RPM & RTM
CMS introduces new 10-minute CPT codes for RPM and RTM to streamline clinical workflows and improve billing precision for initial patient engagement.
RPM – 99470:
- Covers the first 10-19 minutes of remote physiologic monitoring treatment management per month
- Can be performed by clinical staff, physicians, or other qualified healthcare professionals
- Requires at least one real-time interactive communication with the patient or caregiver
- Valued at 0.31 work RVUs (half the value of the existing 20-minute code 99457)
RTM – 98979:
- Covers the first 10-19 minutes of remote therapeutic monitoring treatment management per month
- Must be performed by a physician or other qualified healthcare professional
- Requires at least one real-time interactive communication with the patient or caregiver
- Designated as a "sometimes therapy" service
New RPM Device Supply Code:
99445: Device supply and daily recording/transmission for 2-15 days in a 30-day period (reimbursed at the same rate as 99454 for 16-30 days)
New RTM Device Supply Codes:
- 98984: Remote therapeutic monitoring device supply for respiratory system, 2-15 days in a 30-day period
- 98985: Remote therapeutic monitoring device supply for musculoskeletal system, 2-15 days in a 30-day period
- 98986: Remote therapeutic monitoring device supply for cognitive behavioral therapy, 2-15 days in a 30-day period
These codes recognize that meaningful clinical engagement can occur in focused, brief interactions and establish minimum standards for patient communication. The changes are effective January 1, 2026.
Elimination of SDOH Code G0136
CMS proposes eliminating HCPCS code G0136, previously used for social determinants of health (SDOH) assessments. Instead, providers should incorporate SDOH activities within standard Evaluation and Management (E/M) codes. This reflects the understanding that addressing social determinants should be an integral component of comprehensive patient care rather than a separate billable service.
Removal of G0511 and G0512
CMS will phase out codes G0511 (sunset in 2025) and G0512 (discontinued in 2026) for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Following elimination, these facilities must report individual CPT/HCPCS codes for services provided, as detailed in the official CMS documentation.
This transition requires:
- Implementation of standard CPT/HCPCS coding practices
- Staff training on individual code selection
- Updates to practice management systems
- Financial modeling to assess revenue impact
This change promotes billing consistency across healthcare delivery settings.
Flexibility in Remote Monitoring
Providers can now bill RPM and RTM codes alongside APCM codes for the same patient during the same month. This enhanced flexibility supports comprehensive care coordination for patients with complex medical conditions requiring multiple monitoring modalities.
Care Management vs. Care Coordination
CMS provides important clarification distinguishing these two concepts:
Care Management:
- Direct clinical services for chronic or complex conditions
- Examples: CCM, BHI, RPM
- Involves clinical decision-making and treatment modification
- Includes medication management and patient education
Care Coordination:
- Administrative and logistical activities
- Examples: appointment scheduling, record sharing, transportation arrangement
- Facilitates healthcare system navigation
- Supports smooth transitions between providers
Beginning in 2026, care management activities may also count toward care coordination requirements when both services are billed separately for the same patient.
Request for Information (RFI) by CMS
CMS seeks stakeholder input on several emerging healthcare delivery areas:
Key topics include:
- Chronic Disease Coding: Improving diagnosis coding and preventive service coverage
- Wearable Technology: Integrating consumer devices and digital therapeutics into Medicare reimbursement
- Social Isolation: Addressing social determinants and lifestyle barriers affecting health outcomes
- Supportive Services: Incorporating motivational interviewing, health coaching, and peer support programs
Healthcare providers are encouraged to submit comments during the public comment period to help shape future policy development.
Frequently Asked Questions
What is the timeline for implementing the CMS 2026 Proposed Rule changes?
The proposed rule undergoes a public comment period before CMS publishes a final rule, typically several months later. Most provisions take effect January 1, 2026, though some may have different dates.
How will these changes affect reimbursement rates for healthcare providers?
Impact varies by practice type and service mix. Providers offering behavioral health integration, remote monitoring, and care management may see revenue opportunities through enhanced code flexibility. RHCs and FQHCs should conduct financial modeling for the transition.
What steps should healthcare practices take to prepare for the 2026 changes?
Review the proposed rule, assess current billing patterns, develop implementation timelines, train staff on new codes, update documentation templates, and ensure technology systems can accommodate changes. Begin preparation now to ensure smooth transition.
Conclusion
The CMS 2026 Medicare Physician Fee Schedule Proposed Rule represents a significant shift toward flexible billing practices, integrated behavioral health services, and enhanced recognition of care coordination. By aligning rural and traditional provider practices while embracing digital health innovations, CMS aims to improve care delivery and simplify reimbursement processes. Healthcare providers must proactively adapt their workflows, update documentation practices, and train staff to maximize these opportunities while maintaining compliance. Early preparation will ensure smooth implementation and optimal patient care outcomes.