What's Up - PFS RULE Nov 2025
Yes — that announcement is describing a real CY 2026 PFS policy in the final rule, not a MIPS issue. CMS finalized an “efficiency adjustment” that cuts work RVUs and the related intraservice physician time for many non-time-based services by 2.5% for 2026. CMS says it is using its authority to adjust RVUs for “changes in medical practice,” and it built the 2.5% figure by summing the MEI productivity adjustments for 2022 through 2026. The rule’s own example shows a 15-minute skin-tag removal dropping from 0.82 work RVUs to 0.80, and a lumbar decompression code dropping from 15.37 to 14.99 work RVUs.
What it really means in practical payment terms is this: for affected codes, the physician-work portion of the PFS payment is being shaved down a bit before the 2026 conversion factor is applied. It is not a separate claims modifier or MIPS penalty. It is built into the RVU file itself. Because it targets work RVUs, it hits services whose payment depends materially on physician work valuation. CMS proposed this for code families it thinks naturally accrue efficiency over time through improved workflow, experience, and technology, including many procedures, diagnostic tests, and radiology services.
A key nuance: the blog’s wording that this will “disproportionately impact imaging-heavy specialties and some pathology services” is plausible, but not the cleanest description. The rule says the adjustment applies broadly to many non-time-based procedural and diagnostic services, while excluding time-based services such as E/M, care management, behavioral health, telehealth-list services, and MMM maternity codes. So the effect is not “imaging only”; it is broader across procedural/diagnostic medicine. Also, for imaging, this specific policy affects the professional-work side, not the technical component directly. Separate PE and TC policies can still move imaging payments up or down independently.
Another important nuance is that CMS framed this as the first application of a recurring policy. In the proposal discussion reflected in the final rule materials, CMS said it intended to apply an efficiency update on a 3-year cadence after 2026, with the next one expected in CY 2029. So this is not just a one-off haircut; it is more like a new valuation maintenance mechanism layered onto misvalued-code logic.
So, boiled down: the announcement means many non-time-based PFS services in 2026 will carry slightly lower work RVUs because CMS assumes medical practice has become modestly more efficient over the last five years. For any specialty mix heavy in procedural or diagnostic professional services, you would want to model: (1) this 2.5% work cut, (2) the 2026 conversion factor update, and (3) any separate PE/TC changes. That is the right way to see the net payment effect.
I can also pull this apart for pathology specifically—for example, which buckets are likely untouched, which are exposed, and whether the impact is more on PC than TC.
fn1
I think of codes like MRI being time related in that they take 'time", and their RVUs are made nominally with TIME as an RVU input. But these aren't codes that are WHOLLY based on time, like "30 minute office visit." Right?
#
Yes—your intuition is exactly right, and the distinction CMS is making here is a bit subtle but very important.
MRI (and most imaging/pathology codes) are time-informed, not time-based.
• Time-informed:
The RVUs were originally built using estimates of physician time (e.g., minutes to interpret an MRI), along with intensity, training, liability, etc. Time is an input to valuation.
• Time-based (in CMS’s sense):
The service is defined and billed explicitly by time units—for example, a 30-minute psychotherapy session or E/M levels tied to total time. Here, time is not just an input—it defines the code itself.
That’s the key dividing line for this policy.
Why MRI gets hit by the 2.5% cut
Even though MRI interpretation obviously takes time, MRI CPT codes are:
• Fixed-service codes (e.g., “MRI brain w/ contrast”)
• Not billed in units of minutes
• Not defined by crossing time thresholds
So CMS treats them as non-time-based services → eligible for the 2.5% efficiency haircut on work RVUs.
Why E/M and similar codes are exempt
By contrast, codes like:
• Office visits (when selected by time)
• Psychotherapy (e.g., 30, 45, 60 minutes)
• Care management (monthly time accumulation)
are explicitly time-defined in the code descriptor and billing rules. CMS excludes these because:
• You can’t assume “efficiency” without redefining the code itself
• If a 30-minute visit becomes “more efficient,” it’s still billed as 30 minutes
The conceptual model CMS is using
CMS is essentially saying:
• For non-time-based services:
“Over time, physicians get faster / workflows improve → we can trim assumed intraservice time slightly.”
• For time-based services:
“Time is the product—so we leave it alone.”
Where pathology fits (your likely interest)
Most pathology services behave like MRI:
• Surgical pathology (883xx) → not time-based
• Molecular/genomic tests (814xx, PLA codes) → not time-based
• Even though effort and time matter, they are not billed per minute
So they are in scope for the 2.5% reduction—at least on the work RVU portion (when present).
Bottom line
You’ve got it exactly:
MRI codes use time in their valuation, but they are not defined by time, so CMS treats them as non-time-based—and therefore subject to the efficiency cut.
If you want, I can sketch a quick table of which pathology code families likely have meaningful work RVUs (and thus exposure) versus those that are mostly technical and less affected.
fn2
GIVE ME TRADE JOURNALS TOO PLEASE
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Yes. Here are three recent pieces that describe it fairly directly.
1. CAP TODAY — “Medicare physician fee schedule: Modest Medicare pay increase offset by ‘efficiency adjustment’”
This is probably the closest pathology-trade explanation. It says pathologists’ 2026 increase was dampened by the new 2.5% efficiency adjustment, reports CAP’s objections, and notes an important pathology nuance: CMS exempted the time-based pathology consultation codes 80503–80506, but said other pathology services would still have physician work RVUs reduced. Published December 2025.
2. American College of Radiology — “CMS Releases 2026 Medicare Physician Fee Schedule Final Rule”
This is a concise association summary from the radiology side. It gives the big-picture radiology impact and reports that CMS estimated an overall –2% impact for radiology under the final MPFS. Published October 31, 2025, with an update on November 7, 2025.
3. Society of Interventional Radiology — “Medicare Physician Fee Schedule Final Rule for 2026 conversion factor”
This is a good radiology-association explanation with more reimbursement detail. It states that CMS finalized a 2.5% efficiency adjustment to work RVUs and corresponding intraservice physician time for non-time-based services, and it also gives SIR’s estimated specialty impacts, including +2% total RVU impact for interventional radiology, with different facility/nonfacility effects. Published November 6, 2025.
A fourth, if you want a trade-journal radiology version rather than an association site, is Radiology Business, which described CMS as finalizing the controversial 2.5% cut for non-time-based services and framed it specifically as a radiology concern. Published November 3, 2025.
I can also pull out the exact sentences from each piece that best explain the policy.
#
#
Yes. Here are three recent pieces that describe it fairly directly.
1. CAP TODAY — “Medicare physician fee schedule: Modest Medicare pay increase offset by ‘efficiency adjustment’”
This is probably the closest pathology-trade explanation. It says pathologists’ 2026 increase was dampened by the new 2.5% efficiency adjustment, reports CAP’s objections, and notes an important pathology nuance: CMS exempted the time-based pathology consultation codes 80503–80506, but said other pathology services would still have physician work RVUs reduced. Published December 2025. (CAP Today)
2. American College of Radiology — “CMS Releases 2026 Medicare Physician Fee Schedule Final Rule”
This is a concise association summary from the radiology side. It gives the big-picture radiology impact and reports that CMS estimated an overall –2% impact for radiology under the final MPFS. Published October 31, 2025, with an update on November 7, 2025. (American College of Radiology)
3. Society of Interventional Radiology — “Medicare Physician Fee Schedule Final Rule for 2026 conversion factor”
This is a good radiology-association explanation with more reimbursement detail. It states that CMS finalized a 2.5% efficiency adjustment to work RVUs and corresponding intraservice physician time for non-time-based services, and it also gives SIR’s estimated specialty impacts, including +2% total RVU impact for interventional radiology, with different facility/nonfacility effects. Published November 6, 2025. (Society of Interventional Radiology)
A fourth, if you want a trade-journal radiology version rather than an association site, is Radiology Business, which described CMS as finalizing the controversial 2.5% cut for non-time-based services and framed it specifically as a radiology concern. Published November 3, 2025. (Radiology Business)
I can also pull out the exact sentences from each piece that best explain the policy.
FN1
From <https://chatgpt.com/g/g-p-699fbe1fc2c8819189cf64e8233f3a55-danaher-digital-pathology/c/69c5d11c-37d0-83e8-8b1e-e54bf9df0df0>
FN2
From <https://chatgpt.com/g/g-p-699fbe1fc2c8819189cf64e8233f3a55-danaher-digital-pathology/c/69c5d11c-37d0-83e8-8b1e-e54bf9df0df0>
FN3
From <https://chatgpt.com/g/g-p-699fbe1fc2c8819189cf64e8233f3a55-danaher-digital-pathology/c/69c5d11c-37d0-83e8-8b1e-e54bf9df0df0>
