What's New in 2026: Webinar Highlights

Mary Pat Johnson and Rebecca Greenlaw talk about pearls from our What’s New in 2026 & How Can You Prepare for the Changes?  webinar series that highlight key Medicare updates for ophthalmology practices, including an increase in ASC rates, the introduction of two conversion factors now used in calculating Medicare allowed amounts for physician services and the reduction to practice expense RVUs for many services provided in facilities. These changes reinforce the need for practices to understand payment changes coming and how to prepare for 2026.

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Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. 

Hi everyone, welcome. I'm Rebecca Greenlaw. Hello, I'm Mary Pat Johnson. Happy New Year. Thank you for joining us.

Through December, we've been giving our What's New in 2026 and How You Can Prepare for the Changes webinar. We've given it a few times already, and the response has been great. If you've not had a chance to participate in the webinar yet and wish to, we are still offering a few more times in January.

I agree, the attendance on this particular webinar is always pretty good, and this year no exception. Mostly administrators and office managers who typically attend, but I was surprised by the number of physicians who were involved. I think more physicians dialed in this year than they have in years past.

I don't know about you, but the questions I received, Rebecca, during the webinar and then the follow-up focused primarily on just a couple things. Fee schedules, always questions about fee schedules, and then some of the changes we recommended at the end of the webinar having to do with offsetting some of those reimbursement losses. So can we summarize the fee schedule changes, look at the big picture, the good, the bad, and the confusing? Well, there's a little bit of each of those.

So let's start with the good news. Good news is for surgery centers, the rates are up, and if you remember back to mid-summer, the preliminary ASC fee schedule kind of set everyone's hair on fire. It indicated rates would be going down in 2026, but CMS did recognize an error in their calculation. 

They corrected that. So the final answer is we're going to see a 2.6% increase in ASC rates for those practices or those facilities that met their ASC quality reporting measures back in 2024. We always have to remember those quality measures.

Luckily, most ASCs do well, so most are looking at that 2.6% increase. Yeah, and for those that didn't successfully report, they'll see a slightly less reimbursement. Yeah, their numbers still go up, but just not by as much.

Right. I didn't see any other noteworthy changes to ASC reimbursements for things like implants, devices, supplies, and drugs. Yeah, I think that's correct.

The same rules will apply to payments for those items. Most items, as you know, that are part of a facility or a procedure performed in a facility are reimbursed as part of that ASC payment. There are a few that get separate reimbursement, but not much, and really no change to that over the last several years.

Yeah. So let's take a look at physician reimbursement next. Many clients were surprised by the introduction of two conversion factors, and I have been seeing a lot of questions during our webinar on these two different conversion factors.

I think this is the first time that CMS has assigned different allowed amounts based on practice participation, whether participating or nonparticipating in a qualified APM. So for dates of service beginning January 1, 2026, physicians that are participating in qualified APM will have a slightly higher conversion factor than those who are not participating. If you're participating, you'll see a conversion factor of 33.5675, and nonparticipating in a qualified APM will see it 33.4009. I think most eye care professionals will be paid based on the lower of the two conversion factors.

It represents a 3.26% from 2025. The slightly higher conversion factor will be for a minority of the eye care physicians and practices who do participate in an APM, which will result in a 3.77% increase from 2025. Very well stated.

Yeah, I think clients are kind of slowly getting their arms around this. One of the biggest questions I've gotten recently is how do I know if I'm part of an APM? So if you're getting calls from the billing office or someone who's doing claims processing, they may not know the practice's relationship with an APM, but certainly someone at the administrator's level or whoever's been overseeing their MIPS program should be able to have that answer. And this wasn't even the most surprising change in the fee schedule.

So once we get our hands around which conversion factor to use, for 2026, there's been a huge difference in reimbursement based on place of service. So what used to be referred to as the site of service differential. It seems to be exaggerated this year. 

So to clarify, this is the difference between what the physician receives for a service performed in their office compared to what the physician receives for the same procedure performed in a facility. So it doesn't have anything to do with the facility fee, which was a bit confusing. So when physicians take an item or service outside the office and perform it in perhaps a skilled nursing facility, an emergency room, an outpatient hospital, or an ASC, their reimbursement for the professional fee drops just a bit.

So these are services that can be performed in either setting. The higher priced expense, RVU, covers charges incurred when the care is provided in the physician's office, brick and mortar, staffing, supplies, things of that nature. When the service is moved to a facility, those indirect practice expenses are now being handled by the facility.

So Medicare is taking a deeper cut into the physician reimbursement. So for the portion of the indirect practice expenses now allocated based on work RVUs, it's going to be reduced by 50% starting 2026. So the overall change will be about a 10% reduction in the facility-based RVUs.

So let's look at just a few. If in 2026 a physician does a YAG capsulotomy in their office, the allowed amount for being performed in the office is $335. The same YAG going to a surgery center is $275.

Last year, the change was about $100 as well, $319 down to $298. That's for a YAG cap. If we look at SLT 65855, in 2025 the reduction was about $40 from $235 in the office to $197 in the ASC.

In 2026, it's about $70, $245 in the office down to $171 in the ASC. So physicians are going to see minor surgery reimbursements, laser reimbursements have a bigger gap in the physician payment. And office visits aren't immune to this as well.

So if you do an office visit, whether it's an E&M code or an I-code performed in your office setting, the reimbursements much differ than if you do it again in an outpatient setting. So most of your E&M and I-codes saw great increases when performed in the office in 2026, up anywhere from about 4.5% to about 10%. Exact same series of codes, outpatient E&M or I-codes saw huge decreases when it's performed elsewhere, anywhere from about 8% to nearly 13, no, nearly 14% for comprehensive I-code.

So this is going to catch a lot of physicians off guard, I think. And some of them may, we might find them moving more services back to their office that they were previously performing in a surgery center, particularly if it's a surgery center they don't have a financial interest in. Exactly.

Very well stated. So the other last thing I want to talk about, if we have just a second, is the very end of the webinar. This was new for us this year.

Instead of simply explaining what everyone is facing in 2026 and kind of letting the chips fall where they may, we did put our heads together with some clients, some other experts in industry, with the folks from the RCM team to think what tools could we suggest practices implement or changes they implement to might to maybe offset some of these. I think that was probably the most impactful part of the webinar for most folks who responded. And it's really only the last 10 minutes or so.

It wasn't a lot of the discussion, but I think it seemed to have the most impact. And I think clients, at least those who responded following my webinars, were just happy to have someone looking out for how can we protect ourselves. Yeah, I've seen the same feedback.

The fact that we're giving some takeaways of how they can look at, you know, increasing or protecting their reimbursement, really. Right. And usually fairly easy things.

Some reimbursement changes, some utilization changes, maybe introduce a new service or two. So anyway, hopefully someone or each practice gained a little pearl. Hopefully it works out in their favor.

I'm sure they will respond back, letting us know how it ended. Yeah. So like we said, we still do have a few more offerings of this webinar series for January.

Register if you haven't already done so. Some valuable information to take away from that webinar. So on that note, I think we can sign off.

Hope everyone had a great holiday season. Your new year is off to a fantastic start. Thanks for listening.

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