2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Changes to Reimbursement Landscape- HR1 and MPFS

Pdf Summary

Dr. Edward Sun presented an analysis of changes to the Medicare reimbursement landscape affecting gastroenterology (GI) practices for Calendar Year (CY) 2026. Key points include a 3.26% increase in the Medicare Physician Fee Schedule (PFS) conversion factor to 33.40, the first rise in five years. Notably, CMS will release two conversion factors for 2026: 33.57 for Advanced Payment Model (APM) participants and 33.40 for non-APM physicians, with most GI specialists falling into the latter category.<br /><br />Despite the conversion factor increase, CMS finalized a 2.5% efficiency adjustment reducing work Relative Value Units (RVUs) for non-time-based services, reflecting CMS’s belief that advances in technology and workflows have made procedures quicker and less intensive. This expected periodic adjustment aims to account for improved practitioner efficiency but will partially offset payment gains.<br /><br />Significant modifications to Practice Expense (PE) methodology were introduced. CMS challenges the assumption that facility-based physicians bear office maintenance expenses and proposes allocating indirect PE RVUs linked to work RVUs at half the rate for facility (HOPD, ASC) vs. non-facility services. Consequently, payments for facility-based physicians are projected to decrease by 7%, while non-facility payments may increase by 4%. For gastroenterology specifically, total payments are expected to drop about 3%, with a 9% reduction in facility-based payments balanced by a 6% rise in non-facility payments.<br /><br />Overall, these adjustments will reduce physician payments for endoscopy in ambulatory surgery centers (ASCs) and hospitals by approximately $58 million, equating to an 8% cut compared to 2025. Office-based endoscopy and evaluation/management (E/M) services will see a 16% overall revenue increase. Specific procedures such as colonoscopy with biopsy or polypectomy will reimburse less in facility settings but more for certain office-based services like EGD with dilation.<br /><br />Dr. Sun emphasized the need for GI physicians and practices to deepen their understanding of coding, billing, and reimbursement changes amid ongoing productivity pressures and evolving national policy trends.

Asset Subtitle

Edward Sun, MD, MBA, FASGE

Keywords

Medicare reimbursement 2026

Gastroenterology payment changes

Physician Fee Schedule increase

CMS efficiency adjustment

Practice Expense methodology

Facility vs non-facility payments

Endoscopy payment cuts

Advanced Payment Model conversion factor

Evaluation and Management revenue

GI coding and billing updates