CY 2026 HOPPS, MPFS, and Oncology Coding Update

The Centers for Medicare & Medicaid Services (CMS) released the final rules for the calendar year (CY) 2026 Hospital Outpatient Prospective Payment System (HOPPS) on November 21, 2025. Due to the government shutdown, the release of this rule was quite late; some items were addressed and some appear to have been punted or pushed to future rulemaking. Although there are not many changes specific to oncology, below are several impactful updates for 2026.

HOPPS Payment Rates¹
CMS used the CY 2024 claims data to inform rate setting for CY 2026, which follows the usual 2-year difference in data for rate setting due to allowance for 1 year of filing time for billing. CMS finalized a 2.6% increase to the outpatient department (OPD) fee schedule. Based on the market increase under the Inpatient Prospective Payment System of 3.3% and a 0.7% productivity adjustment decrease, this results in a conversion factor (CF) of $91.415 for hospitals that meet the hospital outpatient quality reporting (OQR) requirements and applies the 2% reduction to those that do not with a CF equal to $89.632.

CMS estimates total payments to HOPPS providers will be approximately $101 billion, which is an increase of approximately $8 billion compared to CY 2025 HOPPS pay ments. CMS finalized an increase of 2.6% to payment rates for ambulatory surgical centers (ASCs) that meet the quality reporting requirements under the ASC Quality Reporting Program.

Cancer Hospital Payment Adjustment
For CY 2026, CMS is continuing the additional payments to cancer hospitals utilizing a payment-to-cost ratio (PCR). CMS finalized a target PCR of 0.87 to determine the cancer hospital payment adjustment to be paid at cost report settlement, which includes a 1% reduction.

Procedures Assigned to New Technology APC Groups
When new technology is assigned a billing code, it can be difficult for CMS to establish a payment rate because there are no claims data to determine utilization by and cost for the hospital. Once there are sufficient data, the new technology is moved to a clinically appropriate Ambulatory Payment Classifica tion (APC). Consistent with current policy, for CY 2026, CMS will continue to retain services within the new technology APC groups until sufficient claims data are received to justify reassignment to a clinically appropriate APC. This policy provides flexibility to reassign a service to a clinical APC in less than 2 years if sufficient claims data are received. One new technology specific to radiation oncology is biology-guided radiation therapy (BgRT).

Biology-Guided Radiation Therapy
BgRT uses positron-emitting radiopharma ceuticals to control the delivery of radiation therapy to treat primary and metastatic lung or bone tumors.

Effective January 1, 2025, Healthcare Common Procedure Coding System (HCPCS) codes C9794 and C9795 were replaced by HCPCS codes G0562 and G0563, respectively. For CY 2026, the proposed HOPPS payment rates are based on available CY 2024 claims data. There are no CY 2024 claims for HCPCS codes G0562 and G0563 since they were not effective until CY 2025. However, as HCPCS codes C9794 and C9795 were still in use until December 31, 2024, CMS established the payment rate for HCPCS codes G0562 and G0563 using the available claims data for these 2 codes.

For CY 2026, CMS has designated HCPCS codes G0562 and G0563 as low-volume procedures under the universal low-volume APC policy, given that there are only 16 claims for C9794 and 28 claims for C9795 during the claims period. For CY 2026, CMS assigned HCPCS code G0563 to APC 1525 (New Technology Level 25 ($3501 to $4000) with a payment rate of $3750.50.

Payments of Drugs, Biologicals (Including Biosimilar Products), and Radiopharmaceuticals
Each year CMS assesses payments for drugs and biologicals based on current pricing methodologies, which includes payments for drugs and biologicals considered separately payable based on the assigned APC or pass-through status. For CY 2026, CMS will continue the current payment policy in effect from CY 2013. A few of the finalized policies include the following:

• CMS will continue to package payment for drugs and biologicals estimated at a per-day administration cost less than or equal to $140. This maintains the CY 2025 value.
• CMS will continue to pay for qualifying biosimilar products with an average sales price (ASP) less than the reference biological ASP, for a calendar quarter during an applicable 5-year period at ASP, plus 8% of the reference biological ASP. Biosimilars are excepted from the threshold packaging policy when their reference biologicals are separately paid. These biosimilars will also be paid for separately, even if their per-day cost is below the packaging threshold.

Payment for Diagnostic Radiopharmaceuticals
Historically, diagnostic radiopharmaceuticals have been packaged into the imaging they are performed with and not paid separately. CMS has done this for multiple reasons, the primary one being it believes packaging policies are an inherent principle of HOPPS. However, it also feels strongly about ensuring availability of new and innovative diagnostic services for beneficiaries.

For 2026, CMS will continue to pay separately for any diagnostic radiopharmaceutical with a per-day cost greater than $655; this is an increase from the 2025 value of $630. Any diagnostic radiopharmaceutical with a per-day cost no more than $655 would continue to be packaged under the current policy.

Within the addendum payment files, diagnostic radiopharmaceuticals that exceed the set threshold of $655 have been assigned a status indicator K for easy identification.

Change to 340B Drug Discount Program Remedy
Historically, the 340B Program aimed to provide safety-net hospitals (hospitals serving patients who are low-income, uninsured, or on Medicaid) that qualified as covered entities the opportunity to purchase outpatient medications at discounted prices. Drug companies were required to offer 340B hospital discounts to participate in the Medicaid program. After significant litigation, the previous payment policy was reversed and drugs purchased under the 340B program were again paid at ASP, plus 6%, but CMS is required to repay monies when the policy was to pay ASP, minus 22.5%.

In the Final Remedy rule, CMS applied a 0.5% reduction in the HOPPS CF applicable to nondrug items and services, excluding hospitals that enrolled in Medicare after January 1, 2018. CMS finalized the start date of this policy for CY 2026, stating that the 0.5% reduction would be in effect until the payment reduction reached the estimated $7.8 billion, which CMS estimated would be in CY 2041.

For CY 2026, CMS proposed to revise the annual reduction to the HOPPS conversion factor from 0.5% to 2%. CMS indicated that this revised reduction rate would allow the agency to reach a total offset of $7.8 billion in approximately 6 years, rather than 16 years. However, after receiving and considering many comments, CMS decided to leave the HOPPS CF at 0.5% to allow hospitals additional time to prepare for the financial impact of the new payment rate. CMS stated that retaining the original 0.5% adjustment indicates hospitals should anticipate that we [CMS] will implement a larger adjustment (such as 2 percent or other adjustment greater than 0.5 percent) beginning in CY 2027. CMS further stated that any adjust ment changes would go through the usual annual rulemaking process for CY 2027 and beyond. CMS also proposed and finalized that the CY 2026 HOPPS payment rates used in rate setting under the ASC payment system would not include the offset to the HOPPS CF.

Invoice for Drug Pricing Proposal
In recent years, an increasing number of drug and biological HCPCS codes that do not have ASP, weighted average cost (WAC), average wholesale price (AWP), and mean unit cost (MUC) data available. The drug manufacturer also may not have any sales data, even though there is an HCPCS code for marketing. Typically, this scenario is for new drugs and biologicals and it presents an issue for the Medicare Administrative Contractors (MACs) and, ultimately, CMS to establish payment status indicators. The volume of these codes has continued to rise from 77 drugs and biologicals in CY 2022, to 85 in CY 2023, and 109 in CY 2024.

Within the CY 2025 HOPPS/ASC final rule, CMS finalized the process for invoice drug pricing reporting, effective January 1, 2025. Additionally, the National Uniform Billing Committee created a value code for the reporting of invoice prices of drugs, biologicals, and radiopharmaceuticals for CY 2026 within the UB-04 claim form, value code 92 (Drug/Biologic Invoice Cost).

CMS stated the MACs would use the provider invoice to determine 1) that the drug is not policy-packaged, and 2) that the per-day cost of the drug, biological, thera peutic radiopharmaceutical, or diagnostic radiopharmaceutical is above the threshold packaging amount, as appropriate.

For CY 2026, CMS made 2 technical corrections. For the first condition, it will not be the MACs that determine whether the drug is packaged per policy; CMS will make this determination. For the second condition, the MACs will continue to be tasked with using the provider invoice to determine if the per-day cost of the drug, biological, therapeutic radiopharmaceutical, or diagnostic radiopharmaceutical is above the set threshold packaging amount (ie, $140 for drugs, biologicals, and therapeutic radiopharmaceuticals and $655 for diagnostic radiopharmaceuticals).

Addressing the High Volume of Drug Administrations Furnished in Excepted Off-Campus Provider-Based Departments
According to a 2023 Medicare Payment Advisory Commission (MedPAC) report, chemotherapy services furnished in OPDs have increased from 35.2% in 2012 to 51.9% in 2021. CPT code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) is one of the most frequently billed drug administration codes. According to CMS, when reviewing the assigned rate for 96413, $199.36 (national rate) in the office setting vs $331.69 (national rate) in the outpatient hospital setting, the difference is roughly 178% higher in the facility setting than the office setting. CMS expressed concern not only for the impact on the agency, but to Medicare beneficiaries and their cost share of being treated in the outpatient hospital setting. CMS indicated it also is concerned about the drive to treat more patients in the provider-based department (PBD) setting due to the financial incentive. Most services are paid at a higher rate in the outpatient hospital setting than the office setting. To address what it says are issues with the same services performed in a setting that would financially benefit the provider, CMS proposed to establish a payment policy to ensure site neutrality.

For CY 2026, CMS is moving forward with application of the Medicare Physician Fee schedule (MPFS) relativity adjustment to drug administration codes within APCs 5691, 5692, 5693, and 5694 as it currently does for clinic visits (G0463). Meaning, the excepted PBDs will no longer be paid at the full HOPPS rate; instead, they will be paid at 40% of the rate, a reduction of 60%. CMS believes this rate will align reimbursement to that in the office-based setting and paid under the MPFS.

Table 1 includes all drug administration codes within the selected APCs by CMS to be paid at 40% of the HOPPS rate.

Payment for Radiation Therapy Services
As discussed in the CY 2026 MPFS final rule summary, CMS finalized deletion of the radiation therapy G-codes for imaging guidance (G6001, G6002, G6017) and radiation treatment delivery (G6003 to G6015) because CPT codes 77402, 77407, and 77412 have been revised by the American Medical Association to report these services instead. Nonexcepted off-campus PBDs will no longer be able to report the G-codes and must begin use of the CPT(R) codes effective January 1, 2026.

Nonexcepted off-campus PBDs should continue to append modifier PN to each applicable claim line for these services. CMS emphasizes that this policy is not new, but rather a continuation of current policy adjusting for the newly revised CPT codes and the corresponding deletion of the G-codes. The payment rate in the nonexcepted PBD will equal the technical component rate assigned under the MPFS.

Following comments regarding the proposed APCs for CPT codes 77402, 77407, and 77412, CMS has finalized changes by adjusting each code into higher APCs. Table 2 outlines the proposed and finalized changes.

There are no other changes expected for the rest of CY 2026 that would impact or change the payment policies for outpatient hospitals, but as with everything, stay tuned. Things are always moving quickly, and surprises seem to happen more and more.

Teri Bedard, BA, RT (R)(T), CPC, is executive director of Client and Corporate Resources at Revenue Cycle Coding Strategies in Des Moines, Iowa.

References
1. Medicare program: Hospital outpatient prospective payment and ambulatory surgical center payment systems; quality reporting programs; overall hospital quality star rating; hospital price transparency; and notice of closure of a teaching hospital and opportunity to apply for available slots. Federal Register. November 25, 2025. Accessed December 31, 2025. https://www.federalregister.gov/documents/2025/11/25/2025-20907/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

CY 2026 MPFS Final Rule Highlights

The Centers for Medicare & Medicaid Services (CMS) released the final rules for calendar year (CY) 2026 Medicare Physician Fee Schedule^(MPFS) on October 31, 2025. Although the government was shut down at the time of publication, it is evident that CMS was preparing for the release, and some items appear to have been overlooked, or attention was minimal or lacking. The following highlights the changes for 2026, which will directly impact oncology services.

Payment Rates

Beginning in CY 2026, as required by section 1848(d)(1)(A) of the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015, there will be 2 separate conversion factors (CFs): one for items and services provided by a qualifying Alternative Payment Model (APM) participant; and another for items and services by a nonqualifying APM participant. The CF, which is a value set each year, converts the relative value units (RVUs) of physician work, practice expense, and malpractice of each code and their geographic locations into the assigned CMS payment rate, and is determined by building on the CF from the preceding year.

The update for CY 2026 to the Qualifying APM CF is an increase of $1.22 (3.77%) from the CY 2025 CF to equal $33.5675. The Nonqualifying APM CF is an increase of $1.05 (3.26%) from the CY 2025 CF to equal $33.4009. The breakdown between facility and non-facility settings is estimated per the total allowed charges for CY 2026.

• Hematology/Oncology Combined Impact: total impact: 0%, non-facility impact: 6%, and facility impact: -11%
• Radiation Oncology and Radiation Therapy Centers Combined Impact: total: -1%, non-facility impact: -1%, and facility impact: -2%

Note: even though the CFs increase next year, which in turn should result in positive adjustments to payments, there are 2 payment adjustments CMS has finalized, which nullifies many of the increases.

Efficiency Adjustment

CMS again expressed concern that there is no accountability for gains in efficiency by physicians for non-time-based services as they become more proficient. Services that physicians perform daily or repeatedly throughout their practice would be expected to become more efficient, take less time, and result in less complexity and mental and physical effort. Ultimately, this increased proficiency would result in a decrease in the physician work relative value units (RVUs) and payment for the service. Additionally, 5382 of 9970 codes have never been valued by the American Medical Association (AMA)/Specialty Society RVS Update Committee (RUC) survey; once a code is surveyed, it may take 2-3 years before the values are implemented.

In 2018, the Medicare Payment Advisory Commission (MedPAC), an independent legislative branch agency that provides Congress with analysis and policy advice related to Medicare, recommended to Congress 3 options to address these concerns from CMS. The 3 options included the following:

1. An automatic reduction in the prices of new services and services with high growth rates
2. An extension of the annual numeric target for CMS to reduce the prices of overpriced services
3. An across-the-board reduction to all fee schedule services other than ambulatory evaluation and management (E/M) services.

For CY 2026, CMS is using an efficiency adjustment applied to physician work RVUs and intra-service time for all non-time-based services paid under MPFS. CMS indicated this is based on the "assumption that both the intraservice portion of physician time and the work intensity (including mental effort, technical effort, physical effort, and risk of patient complications) would decrease as the practitioner develops expertise in performing the specific service. As expertise develops, learning leads to enhanced familiarity with the various aspects of a service, variations in the anatomy of each patient, and confidence in the practitioner's own ability to handle unexpected challenges that arise."

The efficiency adjustment is calculated using the Medicare Economic Index (MEI) productivity assignment, a measure of inflation affecting physicians' practice costs and general wage levels. The productivity adjustment to be applied to the MEI percent change moving forward is 0.8% for CY 2026. This percentage will be updated in the CY 2026 MPFS final rule based on the most recent data. The MEI productivity adjustment is like the one used for both inpatient and outpatient payment systems under CMS.

For oncology, the impact would not be significant for hematology/oncology as most services billed by these physicians are time-based services (ie, E/M and drug administration). Radiation oncologists perform E/M, but the bulk of their services are not time-based. This accounts for the projected 1% decrease overall, as well as in non-facility settings. To give an idea of what this will look like for 2026, Table 1 highlights a few oncology-specific codes. The full table of services impacted by this adjustment can be found on the CMS website.

CMS will revise the efficiency adjustment every 3 years. The next update will be applied in CY 2029 and reflect efficiencies gained during the years 2027-2029. This timeline will align with timed updates to the Geographic Price Cost Index and the Malpractice RVUs, which also occur every 3 years.

Site of Service Payment Differential

Over the past several years, CMS has addressed the shift in practice ownership from physicians to hospitals. CMS reported in 1988 that 72% of physicians were full or partial owners in their respective practices. In 2024, data showed that a dramatic decrease had occurred, where only 35.4% of physicians fully or partially owned their practices. This change was not the result of the closure of practices, but rather a shift in ownership to hospitals acquiring physician practices. Physicians in hospital-owned practices have increased by over 47% between 2014 and 2024.

For CY 2026, CMS applied an additional payment adjustment designated as a site of service payment differential. This adjustment will address the potential and belief that there is a duplicative payment for practice expense (PE) incurred by physicians in the facility setting. PE in the office (non-facility) setting accounts for and values the cost of supplies, equipment, and staff for each service. When the physician provides services in the hospital or ambulatory surgical center (facility) setting, there is some PE that is valued for the physician. Typically, this may be for more indirect expenses, not resources directed to the individual patient, but to maintain their practice while working in the hospital. However, with more physicians employed by and/or working in the facility setting, most, if not all, PEs are covered by the hospital. MedPAC raised this concern in their 2018 report to Congress: "In cases when clinicians practice exclusively or almost exclusively in a facility, or where a facility is financing indirect PE for clinicians, payment to both entities for indirect PE costs may be duplicative and unnecessary."

The site of service payment differential is calculated by reducing the portion of the PE RVUs allocated to the physician for performing the service in the facility setting by half of the amount assigned to the indirect PE RVUs in the non-facility setting. The site of service payment differential will impact physicians practicing in the facility setting more than those in the non-facility setting. It is designed to eliminate duplicate valuations of services and better balance payments between facility and non-facility settings for physicians.

For oncology, this is where the greatest impacts are estimated, specifically in hematology/oncology. As mentioned earlier, time-based services are the predominant services billed by hematology/oncology as opposed to radiation oncology. The proposed decreases in services in the facility setting will have a particularly negative impact on E/M visits. CMS estimates a 7%-13% decrease in overall reimbursement for E/M visits, which, when combined with any other services billed by hematology oncologists, results in an estimated 11% decrease in reimbursement for CY 2026. The magnitude of the impact on hematology/oncology will depend on the practice patterns and specialty of any given physician, and does not mean every hematology oncologist will see the same reductions.

Specific Codes and Code Set Valuations

For 2026, CMS addressed multiple misvalued and/or proposed value changes to specific series of new and established Current Procedure Terminology (CPT®) codes. CMS explained that its rationale for the changes is based on values recommended by the RUC and other organizations, which CMS utilizes for assistance in setting appropriate values for codes. The most coding changes for CY 2026 will impact radiation with an overhaul of the external beam treatment delivery codes in both the facility and non-facility settings.

Radiation Oncology Treatment Delivery

CMS introduced significant updates that will substantially impact radiation oncology, particularly freestanding practices. One of the most notable changes is the shift in how CMS calculates PE values for services such as treatment delivery. Rather than relying on PE inputs from the RUC, CMS used audited hospital outpatient prospective payment system (HOPPS) data to recalibrate the PE for technical services, including those commonly used in radiation therapy.

At the September 2024 Current Procedural Terminology (CPT) Editorial Panel meeting, the Panel approved the revision of CPT codes 77402, 77407, and 77412 to establish a technique-agnostic family of codes with imaging guidance bundled into the 3 codes, and the deletion of CPT codes 77385, 77386, and 77014. These services were subsequently reviewed by the RUC, and a valuation recommendation was submitted to CMS for inclusion in the CY 2026 rulemaking. Although CPT codes (77402, 77407, 77412, 77385, 77386, and 77387) were established for CY 2015, CMS has not used them for payment under MPFS in the freestanding center, just in the hospital setting. CMS identified concerns with the packaging of image-guided radiation therapy (IGRT) into some of the treatment delivery codes in the family and not others in 2015. As a result, CMS created 17 HCPCS G codes, mirroring the existing codes (at the time), maintaining CPT code 77014, and establishing values that linked directly to the existing values/inputs for MPFS.

For CY 2026, CMS has deleted the 17 G codes (G6001-G6017) and assigned values to the newly revised CPT codes for payment under MPFS, in conjunction with utilization of HOPPS cost data to establish PE RVUs, as previously described. CMS also used the relationship between the HOPPS ambulatory payment classification (APC) relative weights for APCs 5621, 5622, and 5623 to determine the valuation of PE-only CPT codes 77402, 77407, and 77412 when paid under the MPFS.

To align the relationship between MPFS payment for this code family with the HOPPS payment for this code family, CMS assigned Procedure Status "B" to the technical component of CPT codes 77387 and 77417 to maintain consistency with HOPPS payment for these codes, which are each bundled into payment for the treatment delivery codes, and not separately billable. While this would be appropriate for the external beam treatment delivery codes, it would negatively impact proton therapy centers.

Due to CMS bundling all imaging guidance technical components, proton therapy centers cannot recoup monies for the imaging technology they purchase and utilize, even though guidelines allow for billing. The definitions of the below proton treatment delivery codes do not include imaging guidance within the definitions, nor within the direct PE values of the codes:

• 77520: Proton treatment delivery; simple, without compensation
• 77522: Proton treatment delivery; simple, with compensation
• 77523: Proton treatment delivery; intermediate
• 77525: Proton treatment delivery; complex

Therefore, it would be appropriate for imaging guidance, 77387-TC and 77417, to be reported by the office-based proton center for the imaging guidance performed at the time of treatment delivery. Additionally, guidance from the AMA on the coding changes for CY 2026 highlights that the technical component of imaging guidance (CPT code 77387) is billable with proton treatment delivery codes.

Superficial Radiation Treatment

Superficial radiation therapy and electronic brachytherapy are currently provided using CPT codes:

• 0394T: High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
• 77401: Radiation treatment delivery, superficial and/or ortho voltage, per day, in conjunction with CPT code 77280: Therapeutic radiology simulation-aided field setting; simple, and HCPCS code G6001: Ultrasonic guidance for placement of radiation therapy fields.

In October 2020, HCPCS code G6001 was identified by the Relativity Assessment Workgroup screen due to CMS/Other Medicare utilization exceeding 20,000.

In January 2021, the RUC recommended referring G6001 to the CPT Editorial Panel to develop new code(s) that reflect the different processes of care between the 2 specialties (dermatology and radiation oncology). After a 2-year delay to allow time for re-review, the CPT Editorial Panel created 4 codes and a new subsection to report surface radiation therapy in September 2024. These codes will replace CPT codes 0394T, 77401, and HCPCS code G6001.

CMS accepted the RUC-recommended work RVU for the 2 codes in the family that have a work RVU assigned. CMS also finalized the utilization of APCs 5621 and 5732 to determine the valuation of PE-only CPT codes 77437 and 77438 and the technical component of CPT code 77436. To maintain alignment between MPFS and OPPS payments for this code family, CMS assigned Procedure Status "B" to the technical component of CPT code 77439 to align with the packaging of the code into the treatment delivery CPT codes 77437 and 77438. CMS finalized displaying CPT code 77439 in Addendum B with the professional and technical components, where the technical component is non-payable Procedure Status "B," as well as the global service equal to the payable professional component.

CMS provided Table 2 to assist in better understanding the code and payment status with respect to the updates for CY 2026 for both external beam radiation and superficial radiation therapy.

Proton Beam Treatment Delivery

MPFS payment amounts for proton beam treatment delivery services are contractor-priced and currently determined by local Medicare Administrative Contractors (MACs). CMS has not previously established RVUs for these services due to the unique nature of the equipment costs associated with these services. Given the changes described above to establish RVUs for the new and revised CPT codes for Radiation Oncology and Superficial Radiation Treatment Delivery Services, CMS sought comments on whether to establish RVUs for proton beam treatment delivery services or if there is a more appropriate method. These services are assigned to APCs 5623 and 5625 under the HOPPS with established Medicare payment rates (unlike the contractor pricing in place for these services under the MPFS).

As mentioned previously, CMS sought comments to prevent any billing confusion for IGRT services where the technical component of a service is bundled, but the professional component is separately reported. Unfortunately, CMS did not address this and finalized 77387 as bundled ("B"), meaning the technical component is not separately billable for proton therapy services. The current proton treatment delivery codes do not include IGRT in the treatment delivery, but by indicating 77387-TC as bundled, proton therapy cannot bill the technical component for reimbursement.

CMS indicated that it received many "thoughtful comments" in response to the request and will consider them as part of any future rulemaking.

Scalp Cooling Services

At the September 2024 CPT Editorial Panel Meeting, the 2 current Category III codes (0662T and 0663T) were deleted, and 3 new Category I codes were created:

• 97007: Mechanical scalp cooling, including individual cap supply with head measurement, fitting, and patient education
• 97008: Mechanical scalp cooling; including hair preparation, individual cap placement, therapy initiation, and precooling period
• 97009: Mechanical scalp cooling; provided after discontinuation of chemotherapy, each 30 minutes (List separately in addition to code for primary procedure)

The new codes were surveyed as part of the January 2025 RUC meeting. The codes do not have any physician work; these are practice expense-only services.

CMS did not agree with the RUC-recommended 5 minutes of clinical staff time for 97007; instead, CMS recommends 27 minutes based on the reference code. CMS accepted and proposed all the other RUC-recommended PE inputs for the family without modification.

Payment for Telehealth Services

CMS currently uses a 5-step process for determining services on the Medicare Telehealth Services List. This process involves categorizing each service as "permanent" or "provisional" status rather than one of the 3 Categories. A service is assigned "provisional" status if there is not enough evidence to determine whether the service provides clinical benefit to the patient, but there is enough evidence to suggest that further review may show the clinical benefit.

Beginning with the CY 2026 Medicare Telehealth Services List, CMS is revising the 5-step review by removing steps 4 and 5 for clarity purposes. Services on the Medicare Telehealth Services List would no longer be designated "permanent" or "provisional." All services listed or added on the Medicare Telehealth Services List would be considered included on a permanent basis.

CMS would still reserve the right to remove services included on the Medicare Telehealth Services List based on internal review or feedback received from interested parties. All codes currently on the list (provisional or permanent) will remain on the Medicare Telehealth Services List. Because CMS has already determined that services with a "provisional" designation satisfy the standards represented in steps 1 through 3 in prior rulemaking cycles, the agency does not believe further review would be required to justify their inclusion on the Medicare Telehealth Services List under the revised process. This includes CPT code 77427: Radiation treatment management, 5 treatments, which is now permanent for use with real-time audio/video capabilities.

Physician Supervision of Residents in Teaching Settings

In previous rule-making, CMS established a policy that allows teaching physicians to fulfill supervision requirements to be present for the key or critical portions of services through audio/video real-time communications technology, when services are provided by a resident. This policy was only valid for services furnished at residency training sites located outside an Office of Management and Budget-defined metropolitan statistical area. This distinction was made to increase beneficiary access to Medicare-covered services in rural areas.

CMS again expressed concerns that continuing to permit teaching physicians to bill for services furnished involving residents when they are virtually present, outside the conditions of the public health emergency (PHE) for COVID-19, may not allow the teaching physician to have personal oversight and involvement over the management of the portion of the case for which the payment is sought. Therefore, CMS believes that permitting Medicare payment to continue for this PHE flexibility is no longer necessary.

For 2026 and following a review of the comments received, CMS has revised its proposal. The now-permanent policy allows teaching physicians to have a virtual presence in all teaching settings and only in clinical instances when the service is a 3-way telehealth visit, with the teaching physician, resident, and patient in different locations. The teaching physician will still be able to provide a virtual presence during the key portion of the Medicare telehealth service for which payment is sought, utilizing audio/video real-time communications technology, for all residency training locations.

Social Determinants of Health Services

A primary focus for CMS before 2026 was related to equity in and access to care, as well as how social determinants of health (SDOH) impact the ability to diagnose or treat the patient. To accomplish this, CMS established coding to improve payment accuracy for additional time and resources dedicated to helping patients with serious illnesses as they navigate the health care system or remove health-related social barriers.

After further review of utilization information, CMS believes that the resource costs described by HCPCS code G0136: Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5 to 15 minutes, are already accounted for in existing codes, including but not limited to E/M visits. Therefore, CMS proposed to delete this code for CY 2026. Accordingly, CMS proposed to remove this code from the Medicare Telehealth Services list.

For 2026, CMS has decided not to delete HCPCS code G0136, instead aligning with the current administration's efforts; the agency is redefining code G0136 as: Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes. The code will no longer be used to capture the work of SDOH assessment but instead address the root causes of chronic illness. The provider furnishing G0136 is expected to refer the patient for resources relevant to the assessment findings. CMS indicated standardized, evidence-based nutrition risk-assessment tools include, but are not limited to, the Mini-EAT tool, the Starting the Conversation: Diet tool, and Short Dietary Assessment Instruments. Similar tools for physical activity assessment include but are not limited to the Physical Activity Vital Sign tool, the CHAMPS Physical Activity Questionnaire for Older Adults, the Rapid Assessment of Physical Activity, and the Telephone Assessment of Physical Activity.

HCPCS G0136 is reimbursed when both physical activity and nutritional risk assessment are performed. Only in those clinical scenarios where it is reasonable and supports medical necessity could one be performed, billed, and paid. An example given by CMS includes when a patient has started a new diet, but the physical activity risk assessment has not yet been performed, and is necessary. All other billing rules previously established by CMS for HCPCS G0136 are still applicable. This code is not billable for routine screening, only when tied to one or more known or suspected physical activity or nutritional needs that may interfere with the patient's diagnosis or treatment.

CMS received several comments requesting that the definition of HCPCS G0019 be revised. Specifically, to adjust it by changing "social determinants of health" to "social drivers of health" or a similar term, and to better align with the current terminology used elsewhere. CMS selected "upstream driver(s)" as a more comprehensive term. After reviewing the comments received for the adjusted definition, CMS has finalized removing any mention of SDOH and replaced the term with "upstream drivers" within the definition.

Physician Practice Information Survey

The AMA introduced the Physician Practice Information Survey (PPIS) in 2007, which was meant to collect data on direct and indirect PEs incurred by physicians in their practices. Initial data were collected through a comprehensive survey process for inclusion in the MPFS rate setting process for CY 2010. The updates were incorporated over a 4-year transition period, replacing previous data sources. Since that time, CMS has sought comments on how to best update the data and collection methodology.

The AMA completed the PPIS and Clinician Practice Information Survey at the end of 2024 and shared the results with CMS ahead of the February 10th deadline for inclusion in the upcoming rulemaking cycle.

CMS's initial review of the data from the AMA reveals several concerns related to accuracy, utility, and suitability for replacing the current PE/HR data for payments under MPFS. CMS outlined in more detail some of their concerns:

• Low response rates and representativeness
• Small sample sizes and sampling variation
• Lack of comparability to previous survey data
• Potential measurement error
• Missing and incomplete data submission

Due to these concerns, CMS did not propose or finalize implementing the PE/HR or cost shares from the AMA's survey data for CY 2026. Instead, CMS will maintain the current PE/HR and 2006-based MEI cost shares for CY 2026 MPFS rate setting. The file CMS-1832-F_PEHR was included in the addenda for CY 2026 MPFS final rule and outlines the PE/HR by specialty.

The only additional changes anticipated for CY 2026 pertain to whether Congress will extend the Geographic Practice Cost Indices (GPCI) floor of 1.0000 for the remainder of 2026. It is currently set to expire on January 31, 2026. This will also be the time we find out if the extensions and waivers specific to telehealth services are extended or end, reverting to pre-pandemic settings.

Teri Bedard, BA, RT (R)(T), CPC, is executive director of Client and Corporate Resources at Revenue Cycle Coding Strategies in Des Moines, Iowa.

References

1. Medicare and Medicaid programs; CY 2026 payment policies under the physician fee schedule and other changes to Part B payment and coverage policies; Medicare shared savings program requirements; and Medicare prescription drug inflation rebate program. Federal Register. November 5, 2025. Accessed December 31, 2025. https://www.federalregister.gov/documents/2025/11/05/2025-19787/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-scheduleand-other
2. Medicare Access and CHIP Reauthorization Act of 2015, HR 10, 114th Cong (2015). Accessed December 31, 2025. https://www.govinfo.gov/content/pkg/PLAW-114publ10/html/PLAW-114publ10.htm

2026 Oncology Coding Update

The coding updates for 2026 have been released by both the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). The radiation oncology external beam radiation therapy (EBRT) code set has been completely revised, which will affect all cancer centers, and there are new codes for scalp cooling services. This column outlines coding changes specific to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT®) and the Healthcare Common Procedure Coding System (HCPCS) for services that may be provided by or related to services by oncology specialties. Items in red indicate changes for 2026.

ICD-10-CM Diagnosis Coding Updates^1,2

The following ICD-10-CM guidelines took effect on October 1, 2025; the updates run on the fiscal year (FY) calendar. Due to the change to a biannual update to diagnosis coding, additional updates are expected for implementation on April 1, 2026.

Revised Guidelines

Many of the guidelines updated for 2025 focused on the need to code the diagnosis to the highest level of specificity. Language was edited in several sections of the ICD-10-CM Official Guidelines to press this point. The guidelines state the following new additions in 2026:

Chapter 2: Neoplasms (C00-D49)

• Patient admission/encounter chiefly for administration of antineoplastic chemotherapy, immunotherapy and radiation therapy. If a patient admission/encounter is chiefly for the administration of chemotherapy, immunotherapy or external beam radiation therapy for the treatment of a neoplasm, assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.

If the reason for the encounter is more than one type of antineoplastic therapy, code Z51.0 and codes from subcategory Z51.1 may be assigned together, in which case one of these codes would be reported as a secondary diagnosis.

• The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis. If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned.

Revised ICD-10-CM Codes: Effective October 1, 2025

The available codes continue to expand, allowing for greater specificity in diagnosis coding. Codes related to malignant inflammatory neoplasm of the breast have been added. The following highlights ICD-10-CM coding changes for 2026. ICD-10-CM codes in red have been added, and strike-throughs indicate deletions from the codes.

Chapter 2: Neoplasms (C00-D49)

Malignant neoplasms of breast (C50)

• C50 Malignant neoplasm of breast
  • C50.A Malignant inflammatory neoplasm of breast — Inflammatory breast cancer (IBC)
  • C50.A0 Malignant inflammatory neoplasm of unspecified breast
  • C50.A1 Malignant inflammatory neoplasm of right breast
  • C50.A2 Malignant inflammatory neoplasm of left breast

Benign neoplasms, except benign neuroendocrine tumors (D10-D36)

• D12 Benign neoplasm of colon, rectum, anus and anal canal
  • D12.6 Benign neoplasm of colon, unspecified
  • ~~Excludes1: inflammatory polyp of colon (K51.4-)~~
  • Excludes2: inflammatory polyp of colon (K51.4-)

Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes (D37-D48)

• D48 Neoplasm of uncertain behavior of other and unspecified sites
  • D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
  • D48.11 Desmoid tumor — Aggressive fibromatosis

Chapter 3: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)

Nutritional anemias (D50-D53)

• D53 Other nutritional anemias
  • D53.8 Other specified nutritional anemias
  • ~~Excludes1: nutritional deficiencies without anemia, such as: copper deficiency NOS (E61.0), molybdenum deficiency NOS (E61.5), zinc deficiency NOS (E60)~~
  • Excludes2: nutritional deficiencies without anemia, such as: copper deficiency NOS (E61.0), molybdenum deficiency NOS (E61.5), zinc deficiency NOS (E60)

Coagulation defects, purpura and other hemorrhagic conditions (D65-D69)

• D68 Other coagulation defects
  • D68.3 Hemorrhagic disorder due to circulating anticoagulants
  • D68.31 Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
    • D68.312 Antiphospholipid antibody with hemorrhagic disorder
    • ~~Excludes1~~ → Excludes2: antiphospholipid antibody syndrome (D68.61), antiphospholipid antibody with hypercoagulable state (D68.61), lupus anticoagulant (LAC) with hypercoagulable state (D68.62), systemic lupus erythematosus [SLE] inhibitor with hypercoagulable state (D68.62)
  • D68.6 Other thrombophilia
  • D68.61 Antiphospholipid syndrome
    • ~~Excludes1~~ → Excludes2: anti-phospholipid antibody with hemorrhagic disorder (D68.312), lupus anticoagulant syndrome (D68.62)
  • D68.62 Lupus anticoagulant syndrome
    • ~~Excludes1~~ → Excludes2: anticardiolipin syndrome (D68.61), antiphospholipid syndrome (D68.61)
    • Added Excludes2: lupus anticoagulant (LAC) with hemorrhagic disorder (D68.312)

Other disorders of blood and blood-forming organs (D70-D77)

• D71 Functional disorders of polymorphonuclear neutrophils
  • D71.1 Leukocyte adhesion deficiency — LAD-I, LAD-II, LAD-III, Leukocyte adhesion deficiency type I, Leukocyte adhesion deficiency type II, Leukocyte adhesion deficiency type III
  • D71.8 Other functional disorders of polymorphonuclear neutrophils — Cell membrane receptor complex [CR3] defect, Chronic (childhood) granulomatous disease, Congenital dysphagocytosis, Progressive septic granulomatosis
  • D71.9 Functional disorders of polymorphonuclear neutrophils, unspecified

Certain disorders involving the immune mechanism (D80-D89)

• ~~Excludes1: functional disorders of polymorphonuclear neutrophils (D71)~~
• Excludes1: functional disorders of polymorphonuclear neutrophils (D71-)

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

Inflammatory polyarthropathies (M05-M14)

• M05 Rheumatoid arthritis with rheumatoid factor
  • M05.A Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis — Code first rheumatoid arthritis with rheumatoid factor by site, if known (M05.00 to M05.8A)

Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99)

Encounters for other specific health care (Z40-Z53)

• Z40 Encounter for prophylactic surgery
  • Z40.0 Encounter for prophylactic surgery for risk factors related to malignant neoplasms
  • Use Additional: ~~code to identify risk factor~~ → code to identify risk factor, such as genetic susceptibility to malignant neoplasm Z15.-
  • Z40.02 Encounter for prophylactic removal of ovary(s)
  • ~~Encounter for prophylactic removal of ovary(s) and fallopian tube(s)~~
  • Z40.8 Encounter for other prophylactic surgery
  • Z40.81 Encounter for prophylactic surgery for removal of ovary(s) for persons without known genetic/familial risk factors — Encounter for prophylactic oophorectomy for persons without known genetic/familial risk factors
  • Z40.82 Encounter for prophylactic surgery for removal of fallopian tube(s) for persons without known genetic/familial risk factors — Encounter for prophylactic salpingectomy for persons without known genetic/familial risk factors, Opportunistic salpingectomy
  • Z40.89 Encounter for other prophylactic surgery
• Z85 Personal history of malignant neoplasm
  • Z85.4 Personal history of malignant neoplasm of genital organs
  • Z85.4A Personal history of malignant neoplasm of fallopian tube(s)
• Z86 Personal history of certain other diseases
  • Z86.0 Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior
  • Z86.00 Personal history of in-situ neoplasm
    • Z86.00A Personal history of in-situ neoplasm of the fallopian tube(s)

Revised ICD-10-CM Codes: Effective April 1, 2026

Chapter 2: Neoplasms (C00-D49)

Benign neoplasms, except benign neuroendocrine tumors (D10-D36)

• D18 Hemangioma and lymphangioma, any site
  • ~~Excludes1~~ → Excludes2: benign neoplasm of glomus jugulare (D35.6), blue or pigmented nevus (D22.-), nevus NOS (D22.-), vascular nevus (Q82.5)

Neoplasms of unspecified behavior (D49)

• D49 Neoplasms of unspecified behavior
  • ~~Excludes1: neoplasms of uncertain behavior (D37-D44, D48)~~
  • Excludes2: neoplasms of uncertain behavior (D37-D44, D48)

Chapter 3: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)

Nutritional anemias (D50-D53)

• D51 Vitamin B12 deficiency anemia
  • ~~Excludes1: vitamin B12 deficiency (E53.8)~~
  • Excludes2: vitamin B12 deficiency (E53.8)

Other disorders of blood and blood-forming organs (D70-D77)

• D72 Other disorders of white blood cells
  • ~~Excludes1: neutropenia (D70)~~
  • Excludes2: neutropenia (D70)
  • D72.8 Other specified disorders of white blood cells
  • D72.81 Decreased white blood cell count
    • ~~Excludes1: neutropenia (D70.-)~~
    • Excludes2: neutropenia (D70)
  • D72.819 Decreased white blood cell count, unspecified
    • ~~Excludes1: malignant leukopenia (D70.9)~~

Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94)

• R92 Abnormal and inconclusive findings on diagnostic imaging of breast
  • R92.3 Mammographic density found on imaging of breast
  • R92.31 Mammographic fatty tissue density of breast
    • ~~Breast Imaging Reporting and Data System (BI-RADS): A~~
    • Breast density category within Imaging Reporting and Data System (BI-RADS): A
    • ~~Breast Imaging Reporting and Data System (BI-RADS): 1~~
  • R92.32 Mammographic fibroglandular density of breast
    • ~~Breast Imaging Reporting and Data System (BI-RADS): B~~
    • Breast density category within Imaging Reporting and Data System (BI-RADS): B
    • ~~Breast Imaging Reporting and Data System (BI-RADS): 2~~
  • R92.33 Mammographic heterogeneous density of breast
    • ~~Breast Imaging Reporting and Data System (BI-RADS): C~~
    • Breast density category within Imaging Reporting and Data System (BI-RADS): C
    • ~~Breast Imaging Reporting and Data System (BI-RADS): 3~~
  • R92.34 Mammographic extreme density of breast
    • ~~Breast Imaging Reporting and Data System (BI-RADS): D~~
    • Breast density category within Imaging Reporting and Data System (BI-RADS): D
    • ~~Breast Imaging Reporting and Data System (BI-RADS): 4~~

CPT® Coding Updates

External Beam and Image-Guided Radiation Therapy: Revised Codes

The below 3 AMA codes are now used for the coding of radiation oncology EBRT and 1 for the coding of IGRT. Due to the revisions, all cancer centers, regardless of setting (ie, hospital based or freestanding) will use the updated AMA codes. There are no longer differences between sites of service for reporting EBRT and IGRT. Additionally, all payers are requiring providers to begin using the revised coding convention effective January 1, 2026. The need for reauthorization of treatments is mixed: Some payers are requiring any patients who cross over from 2025 to 2026 to be reauthorized for treatment, some are not, and still others are giving providers a window to begin the process.

• 77402: Radiation treatment delivery; Level 1 (eg, single electron field, multiple electron fields, or 2D photons), including imaging guidance, when performed
• 77407: Radiation treatment delivery; Level 2 single isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed
• 77412: Radiation treatment delivery; Level 3 multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) OR a single isocenter photon therapy (eg, 3D or IMRT) with active motion management, OR total skin electrons, OR mixed electron/photon field(s), including imaging guidance, when performed
• 77387: Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed (Do not report technical component [TC] with 77371, 77372, 77373, 77402, 77407, 77412.) (For placement of interstitial device[s] for radiation therapy guidance, see 31627, 32553, 49411, 55876.)

With adoption of the above codes, the following codes have now been deleted:

• 77014: Computed tomography guidance for placement of radiation therapy fields
• 77385: Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple
• 77386: Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex
• G6001: Ultrasonic guidance for placement of radiation therapy fields
• G6002: Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy
• G6003: Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 mev
• G6004: Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 mev
• G6005: Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 mev
• G6006: Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 mev or greater
• G6007: Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: up to 5 mev
• G6008: Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 6-10 mev
• G6009: Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 11-19 mev
• G6010: Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 20 mev or greater
• G6011: Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 mev
• G6012: Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev
• G6013: Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev
• G6014: Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater
• G6015: Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session
• G6016: Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session
• G6017: Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

Superficial Radiation Therapy: New Codes

Four AMA codes are now used for the coding of superficial radiation therapy. This technology is specific to patients with skin cancer and may be administered by dermatology or radiation oncology. None of the new codes are used with EBRT as previously described; these codes are a new set unto themselves:

• 77436: Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting
• 77437: Surface radiation therapy; superficial, delivery, <150 kV, per fraction (eg, electronic brachytherapy)
• 77438: Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction
• 77439: Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure)

Superficial Radiation Therapy: Deleted Codes

• 77401: Radiation treatment delivery, superficial and/or ortho voltage, per day
• 0394T: High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
• G6001: Ultrasonic guidance for placement of radiation therapy fields

Scalp Cooling: New and Deleted Codes

There are now 3 new Category I codes to represent scalp cooling services:

• 97007: Mechanical scalp cooling, including individual cap supply with head measurement, fitting, and patient education
• 97008: Mechanical scalp cooling; including hair preparation, individual cap placement, therapy initiation, and precooling period
• 97009: Mechanical scalp cooling; provided after discontinuation of chemotherapy, each 30 minutes (List separately in addition to code for primary procedure)

These new codes replace the previous 2 Category III codes, now deleted:

• 0662T: Scalp cooling, mechanical; initial measurement and calibration of cap
• 0663T: Scalp cooling, mechanical; placement of device, monitoring, and removal of device (List separately in addition to code for primary procedure)

Risk Assessment

Following other changes to codes or use of the term social determinants of health (SDOH) by the current administration, CMS has made changes to codes that include or are specific to management of SDOH and replaced with the term upstream drivers. These changes have impacted 2 codes that were new in 2024, G0136 and G0019.

• G0136 (New): Administration of a standardized, evidence-based assessment of physical activity and nutrition, 5 to 15 minutes, not more often than every 6 months
• ~~G0136 (Old): Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes~~
• G0019 (New): Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month, in the following activities to address upstream driver(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating visit.
• ~~G0019 (Old): Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner, 60 minutes per calendar month, in the following activities to address social determinants of health (SDOH) need(s) that are significantly limiting the ability to diagnose or treat problem(s) addressed in an initiating visit.~~

Teri Bedard, BA, RT (R)(T), CPC, is executive director of Client and Corporate Resources at Revenue Cycle Coding Strategies in Des Moines, Iowa.

References

1. ICD-10. Centers for Medicare & Medicaid Services. Updated December 18, 2025. Accessed January 9, 2026. https://www.cms.gov/medicare/coding-billing/icd-10-codes
2. ICD-10-CM files. Centers for Disease Control, National Center for Health Statistics. June 7, 2024. Accessed January 9, 2026. https://www.cdc.gov/nchs/icd/icd-10-cm/files.html
3. AMA releases CPT 2026 code set. American Medical Association. September 11, 2025. Accessed January 9, 2026. https://www.ama-assn.org/press-center/ama-press-releases/ama-releases-cpt-2026-code-set
4. HCPCS quarterly update. Centers for Medicare & Medicaid Services. Accessed January 9, 2026. https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update