Special Advocacy News

• Medicare calls for slight increase for pathologists in 2026
• Key Medicare fee schedule provisions outlined
• New: Pathology MVP added to 2026 QPP
• Changes in Advanced APMs explained

Next year's Medicare Physician Fee Schedule proposes cuts to pathology work relative value units (RVUs), known as "efficiency adjustments," that the CAP vigorously opposes. However, the "One Big Beautiful Bill Act" will increase overall physician spending by 2.5% in 2026, resulting in a net 0.56% increase in pathology spending for 2026.

• The temporary pay increase helps for now, but the CAP continues to advocate to stabilize and reform the Medicare payment system.

Go deeper: Review our impact table comparing changes to pathology services from current to next year’s payments.

Next steps: The CAP will provide comments to the Centers for Medicare and Medicaid Services (CMS) within the next 60 days on the proposals that impact the specialty.

Save the date: On August 5. We’ll review changes to the 2026 Medicare fee schedule and Quality Payment Program regulations.

Factors negatively impacting pathology in the proposed 2026 fee schedule include a proposed efficiency adjustment to the physician work RVUs.

• According to CMS, it "may help to improve the overall accuracy of valuation of services under the PFS."

CPT Codes for CAR-T Therapy Services

In 2023, the CAP and a multispecialty group developed four new category I CPT codes to describe the procedures required for creating and administering CAR-T therapy, which is a treatment for certain types of cancer. 

Despite agreeing with recommended work RVUs, CMS decided to bundle payment for CAR-T cell harvesting and preparation into one code. 

• This meant no separate payments for each service under the fee schedule or hospital outpatient prospective payment system.
• The policy took effect on January 1, 2025.

The CAP met with CMS to oppose the finalized policy, arguing it doesn't recognize pathologists' work.

• CMS should pay separately for each CPT code service.
• The CAP followed up with a letter to CMS seeking clarity on the policy.

CMS still proposes not providing separate payment, but the agency is now soliciting comments on this policy. 

What's next: The CAP will continue to advocate on this important issue.   

By the numbers: According to CAP calculations, the proposed fee schedule will result in a 0.56% increase in pathology payments from 2025. 

• The non-APM qualifying conversion factor for 2026 is $33.4209, up 3.3% from 2025, largely due to an adjustment from the One Big Beautiful Bill Act.
• The CAP is actively lobbying Congress to ensure that this increased funding is made permanent.

For the first time, MIPS Value Pathways (MVPs) will include a pathology-specific track in the 2026 Quality Payment Program (QPP). CMS continues to state that MVPs will eventually be the only way to report MIPS. 

• Details: It includes publicly-available clinical quality measures, measures from our Pathologists Quality Registry, and other private measures. The MVP also includes some activities that pathologists are not eligible for.
• Contact: For information about reporting the Pathology MVP, email us at mips@cap.org.

Other 2026 QPP changes: The proposed rulemaking keeps the performance threshold at 75 points for 2026 through 2028 and the data completeness threshold at 75% of all eligible cases.

• Impact on pathologists: The CAP opposes any further increases to the performance threshold or data completeness requirement, and has advocated in the past for lowering both.
• Stability: CMS has not proposed adding or removing any quality measures from the Pathology Specialty Measure Set. A stable measure set helps practices know what to expect in the following year.
• Removal of Improvement Activities: As previously finalized, for 2026, CMS will remove some of the most highly used Improvement Activities. Practices will need to find alternatives. 

Digital measurement: CMS seeks input on driving the transition to digital quality measurement. 

• The CAP supports digital measurement as long as it reduces burdens and unnecessary system updates but urges caution against moving to an immature data standard.

CAP support: Practices are encouraged to review scoring changes and contact CAP for guidance on high-scoring measures, email us at mips@cap.org. 

CMS is emphasizing a shift in health care delivery, aiming for all traditional Medicare beneficiaries to be in accountable care models by 2030.

• This aligns with efforts to transform how health care is managed and delivered nationwide.

What's new: In the latest proposed rule, CMS outlines adjustments in beneficiary attribution for QP status determinations.

• These changes are designed to encourage participation in Advanced APMs and enable more specialists to participate.

Why it matters: Clinicians in Advanced APMs achieving QP or Partial QP status is exempt from MIPS reporting and payment adjustments.

• This exemption provides significant administrative relief and financial incentives for eligible participants.

Details: Congress has also extended the APM Incentive Payment amount to 1.88% for the 2026 payment year.

• This reflects ongoing legislative support to encourage participation in these models.