CMS CY2026/27 Payment and Coding Changes
Key Questions
What is the updated FQHC PPS rate for CY2026/27?
The FQHC PPS rate increases by 2.5% to $207.72 and now includes a separate APCM payment. This change is part of broader CMS payment updates for Federally Qualified Health Centers.
What is happening to the G0511 code under the new rules?
G0511 is being sunset as part of the CY2026/27 payment and coding changes. Providers should review alternative codes for related services moving forward.
What telehealth updates are included in MBPM Chapter 13?
MBPM Chapter 13 includes updates on telehealth services for FQHCs and RHCs. These changes align with 42 CFR rules on coverage and reimbursement.
How does the 2027 ACA final rule affect eligibility checks and user fees?
The final rule introduces stricter eligibility checks and reduces user fees, which will reshape the payer mix for ACA exchanges. This impacts how plans verify enrollee eligibility and manage costs.
What is the proposed rule on state directed payments and FFS supplementals?
The proposed rule addresses Medicaid managed care state directed payments and fee-for-service supplementals, with comments due by July 21. It aims to clarify financing and payment methodologies for states.
Are there updates to CLFS and CLIA HCPCS lab coding?
Yes, quarterly CLFS/CLIA HCPCS lab coding updates are included in the highlight. These cover waived tests and reasonable charge payments for laboratories.
How might these CMS changes affect medical billing contracts?
Policy updates like the FQHC rate changes and ACA modifications will require adjustments to billing contracts and operating decisions. Providers should monitor how coverage and reimbursement rules evolve.
What 42 CFR rules are referenced in these CMS updates?
The updates reference 42 CFR sections on allowable costs, direct supervision, and definitions for practitioners in RHCs and FQHCs. These rules govern coverage, reimbursement, and operational requirements.
FQHC PPS +2.5% to $207.72 with separate APCM; G0511 sunset; MBPM Ch13 tele updates; 42 CFR rules. 2027 ACA final rule eligibility checks and user fee cuts reshaping payer mix. Includes quarterly CLFS/CLIA HCPCS lab coding updates and proposed rule on state directed payments/FFS supplementals (comment to July 21).