The Centers for Medicare & Medicaid Services (CMS) released its 2026 proposed rules for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS). SNMMI is reviewing all provisions and will provide a more detailed analysis in the near future, as well as submitting comments to CMS.
Key provisions that will impact nuclear medicine from both proposed rules are summarized below; the full explanation is available HERE.
- For SNMMI-prepared Medicare Physician Fee Schedule Chart click here.
- For SNMMI-prepared HOPPS Rate-APC Chart click here.
A fact sheet on the final rules may be found here for MPFS and here for OPPS.
Hospital Outpatient Prospective Payment System (OPPS) – Key Nuclear Medicine Updates
- Payment
for Diagnostic Radiopharmaceuticals
- CMS
will continue using mean unit cost (MUC) as the payment method for
separately payable diagnostic radiopharmaceuticals with per-day costs
>$655 (threshold proposed for CY 2026).
- ASP
(Average Sales Price) reporting remains voluntary under OPPS but is
encouraged. CMS seeks input on challenges/barriers to ASP reporting.
- Packaging
Threshold Increase
- Proposed
increase from $630 to $655 per day for radiopharmaceutical packaging
threshold for CY 2026, adjusted for inflation (based on the Producer
Price Index).
- CMS
indicates that 30 diagnostic radiopharmaceuticals would qualify for
separate payment under the increased threshold.
- New
Add-On Payment for Tc-99m
- A
$10 add-on payment will begin in 2026 for Tc-99m doses derived from
domestically produced Mo-99, to support U.S. supply chain and national
security.
- This
replaces the old add-on, which rewarded production without highly
enriched uranium (HEU).
- The
add-on requires that ≥50% of Mo-99 come from U.S. sources; new HCPCS code
C917X will be created for billing.
Medicare Physician Fee Schedule (MPFS) – Key Nuclear Medicine Updates
- Conversion
Factor Update for 2026
- CMS
proposes two conversion factors:
- $33.5875
for qualifying APM participants (QPs) — 3.83% increase.
- $33.4209
for non-QPs — 3.62% increase.
- Determination
of relative value units
- All
PET and PET/CT CPT codes (technical and global) remain at contractor price,
consistent with SNMMI advocacy.
- New
Efficiency Adjustment Proposal: CMS proposes a 2.5%
reduction in work RVUs and physician time for non-time-based codes (e.g.,
procedural services), applied every 3 years.
- Site-of-Service
Payment Differential: CMS proposes changes to
indirect practice expense RVUs based on practice ownership and site of
service. This would reduce facility-based practice expense RVUs by 7% and
increase non-facility-based RVUs by 4%.
- Malpractice
RVU Update: CMS will use updated 2026 malpractice premium data
from state insurance filings to revise malpractice RVUs.
- Software-as-a-Service
Reimbursement: CMS is requesting feedback on
how to price services using software-as-a-service models and whether OPPS
rates can be used as benchmarks.
Quality Programs and MIPS
- MIPS
Performance Threshold
- The
75-point threshold to avoid penalties remains through the 2026–2028
performance years (2028–2030 MIPS payment years).
- New
MIPS Value Pathways
- CMS
proposes six new MIPS Value Pathways, including a focus on diagnostic and
interventional radiology.
- CMS
will also update measures impacting MIPS performance pathways.