Special Advocacy News

• 2026 Medicare fee schedule includes policy lowering pathology and other specialists' pay
• How changes to Quality Payment Program rules will affect pathologists
• New updates to advanced alternative payment models (APMs)

Next year’s Medicare Physician Fee Schedule was released late in the day on October 31. 

Despite strong opposition from the CAP and other medical specialties, the Centers for Medicare & Medicaid Services (CMS) is moving forward with several policy changes that will negatively affect pathology reimbursement. 

For pathologists: The CMS is applying “efficiency adjustments” based on its view that productivity gains are not fully captured in the physician work component of RVUs used to calculate payment. 

• These reductions affect nearly all billed pathology services, including key CPT codes such as 88305, 88312, and 88341.
• The CAP strongly opposed finalization of this policy, engaging with CMS, congressional leaders, and CAP members through grassroots efforts to highlight the flaws in the adjustment. Although the adjustment was finalized, the CAP will continue to advocate for reversal of this payment cut. 

The CMS did agree with the CAP to exclude time-based codes from the efficiency adjustment, that the time-based pathology clinical consultation codes (80503, 80504, 80505, and 80506) must be removed from this adjustment. 

Temporary relief: The One Big Beautiful Bill Act provided a temporary offset by increasing overall physician spending by 2.5% in 2026, resulting in an estimated 0.5% net increase in pathology reimbursement for 2026. The impact for an individual pathologist varies depending on case mix as the CMS' policies vary on a code-by-code basis.

• The non-APM qualifying conversion factor for 2026 is finalized at $33.4009, a 3.3% increase from 2025, driven largely by this legislative adjustment.
• 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.

• In December, we’ll discuss these changes and more during a webinar, which we’ll formally announce in the coming days. 

In its final 2026 QPP regulations, the CMS will leave the performance threshold at 75 points for next year’s reporting. 

The impact: Maintaining the current threshold is better than an increase, which adds further burdens on pathologists.

The CMS is also maintaining the data completeness threshold at 75 points. And, no measures were added to or removed from the Pathology Specialty Measure Set and the Pathology QPP measures will remain worth a maximum of 10 points for practices who score 100%.

The CMS also continues to carry out MIPS Value Pathways (MVPs) including for the first time a Pathology.

• The Pathology MVP includes MIPS Clinical Quality Measures (CQMs) and QCDR measures from the Pathologists Quality Registry as well as a commercial QCDR, MSN Healthcare.   
• Several of the Improvement Activities (IAs) included in the MVP are not applicable to pathologists.
• The MVP also includes other aspects of the MIPS program that do not apply to pathologists such as population health measures and Promoting Interoperability activities.
• For information about reporting the MVP, contact mips@cap.org

What's next: The CAP continues to advocate for pathologists’ success in the MIPS program.

• We encourage practices (and their billing companies) to review the scoring changes and contact CAP at mips@cap.org to understand the availability of higher-scoring measures and how to best report them. 

For the Advanced APM track, if an eligible clinician participates in an Advanced APM and achieves Qualifying APM Participant (QP) or Partial QP status, they are excluded from the MIPS reporting requirements and payment adjustment. 

The impact: According to CMS, the agency continues to focus on transforming health care delivery towards the goal of having all traditional Medicare beneficiaries in an accountable care relationship with their health care provider by 2030. 

• To achieve this, the CMS has finalized changes to how QP status is determined to include both individual and group determinations. 

Also, the CMS has also expanded the definition of “attribution-eligible” Medicare beneficiaries to remove the necessity that a participating clinician bill an evaluation and management code for a beneficiary to be attributed to an APM. 

Taken together, the CAP believes these proposals could lead to an increase in APM participation for pathologists, although the impact remains to be seen in coming years.