- August 26, 2025
- Posted by: Josh Knoll
- Category: Cardiology Billing
2026 is not so far away, and it’s not just another year for your cardiology billing practice; rather, it’s a year of some major possible changes. The Centers for Medicare and Medicaid Services (CMS) has already proposed some vital rules for the upcoming year. These vital rules will redefine how you manage your cardiology billing in 2026 and impact your bottom line, too. Let’s explore those rules carefully here-
Highly possible changes in the cardiology billing process proposed by CMS for 2026:
New Medicare conversion factor is more than just a number:
You already know that the conversion factor is the number that CMS uses to determine how much you should get reimbursed for a cardiology procedure. There are two conversion factors for cardiology practices that are coming under or not under the Alternative Payment Model (APM). The CF is $33.5875 when your practice is in APM, and it is almost a 3.8% increase. Your CF is $33.4209 when you are not coming under APM, and it is almost a 3.3% increase. Now, CMS predicts that cardiology reimbursements may see almost 1% overall rise but this Impact depends on your practice. Facility-based practices may expect a 6% drop, while services that are non-facility based may see an increase of 5%.
Related Reading: Breaking Cardiology Billing Barriers with an Expert
Highly possible changes in cardiology billing codes: a rollercoaster ride for payments:
You may find the new 2026 rules like a rollercoaster ride for your overall cardiology billing services, including the addition and deletion of codes. One vital change that you can expect is in Left Atrial Appendage closure, as CMS has proposed almost 27% reduction. You can expect the overall work value to drop from 14.00 to 10.25 and the American College of Cardiology is already fighting for this particular cut. Your practice could be adversely impacted if you perform this particular procedure often, and it may even limit patient access as well. There is a mix of good and bad news for Percutaneous Coronary Intervention codes as CMS accepted RUC-recommended values for 12 revised codes.
The good thing is the addition of new codes for challenging stent cases and chronic total occlusion revascularization, allowing your practice to bill more precisely for challenging cases. However, your billing job can be more challenging because of the expansion of new lower extremity revascularization (LER) codes as the number of such codes is going to be 46 from 16, making your billing more detailed with all the accepted RUC-recommended values. A new code was added for AI-powered coronary plaque assessment, showing CMS is open to innovation. Baroreflex Activation Therapy (BAT) gets seven new codes, most of which were accepted, while one was reduced. You can expect the Remote Physiologic Monitoring codes to hold their value intact until 2028. The reality is that cardiology billing service is going to become more complex, detail-oriented, and tied to advanced technology, hence making it imperative for you to stay prepared to adapt.
The major adjustments in efficiency and practices expenses:
There would be two big adjustments in your cardiology billing game. CMS is already planning to apply the proposed -2.5% efficiency adjustment for all the non-time-based codes. The main idea behind this change is to reduce the value of services to show that physicians have become faster and more efficient over time. You can expect this cut to roll out every 3 years and offset any increase in the conversion factor. Your overall revenue could be affected as it directly impacts your procedures. Another possible change is the practice expense that covers your overhead costs. CMS believes that paying the same practice expenses for hospital-based and facility-based is not a good idea. They want to reduce indirect PE for facility-based services by 50%, thus resulting in a 10% drop in total RVUs for many procedures like pacemaker implants, TAVR, and ablations.
New models and quality programs: A shift to accountability
The rules are intended to move your cardiology practice closer to value-based care. CMS is proposing a mandatory program called the Ambulatory Specialty Model. Specialists who treat a set number of heart failure patients in specific regions will come under this particular model. You will be held financially accountable for managing chronic conditions like heart failure under this model.
The ASM is important because it puts providers in a two-sided risk arrangement, with payment adjustments ranging from -9% to +9%. Performance will be measured through the Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs), but if you join the ASM, you won’t have to participate in MIPS. The program is expected to launch in 2027. At the same time, the proposed rule updates the Quality Payment Program (QPP) and MIPS. The performance threshold remains at 75 points, with some new quality measures added and others removed, along with new MVPs introduced. You need to remember the fact that each of these updates is designed to improve care coordination and push cardiology practices toward delivering higher-value care.
The big takeaway is that billing in 2026 will be more complex than ever, and you will need to be very precise to protect your revenue. You must handle the new dual conversion factors correctly, with different rates for APM participants and non-participants. Your team also needs to master the new codes, from the expanded LER codes to the revised PCI family and the new AI-driven technologies. Missing these updates could mean lost payments. On top of that, the -2.5% efficiency adjustment will directly impact your bottom line, and the new practice expense rules could cause big revenue drops for facility-based services. The upcoming Ambulatory Specialty Model (ASM) also brings two-sided risk, which can either reduce or increase payments depending on performance. The fact is that these are not just some random changes, as they push your practice towards a value-based process. A single mistake in your billing practice can cost you heavily.
Fortunately, a professional cardiology billing company can be the best help for your practice’s financial health. The professional experts in a reputable billing company know how to update your billing system so that you can always ensure clean claims submission. They also understand the financial risks and opportunities of new models like ASM and can guide you through them. Your practice is always likely to see denials and revenue loss with constant updates, changing codes, and stricter payment policies, especially when you are handling your billing process alone. A professional cardiology billing company always helps you get paid accurately and remain financially stable in the present and coming years without any worry.
Related Reading: Cardiology Billing Company: Your Key to Faster Payments and Fewer Denials
Hire SunKnowledge as your cardiology billing service partner:
You always need the right partner to get the optimal benefits of cardiology billing services. We, at SunKnowledge Inc., are the only RCM company that works with both payers and providers, giving us a unique edge in understanding the entire process. We know what it takes to deliver 99.9% accuracy in coding and billing, reduce your overhead costs by up to 80%, and ensure 100% HIPAA compliance with the solid domain experience of more than a decade. Our team manages everything from pre-billing to collections with constant claim monitoring and clear communication. Partnering with us means fewer errors, faster payments, and stronger revenue for your practice. So, schedule a call with us and get our end-to-end RCM services at $7/hour!