CY 2027 PFS Rate Setting and Conversion Factor
As required by statute, beginning in CY 2026, there are two separate conversion factors: one for qualifying alternative payment model (APM) participants (QPs) and one for physicians and practitioners who are not QPs. By statute, QPs are those that meet certain thresholds for participation in an Advanced APM, which means generally that the payment model has features to ensure accountability for quality and cost of care.
The update to the qualifying APM conversion factor for CY 2027 is +0.75% while the update to the non-qualifying APM conversion factor for CY 2027 is +0.25%. The changes to the PFS conversion factors for CY 2027 include these updates as required by statute and an estimated -0.12% adjustment necessary to account for proposed changes in work RVUs for some services. However, Public Law 119-21, which CMS refers to as the Working Families Tax Cut (WFTC) legislation, provided a one-year PFS conversion factor increase of 2.50% for CY 2026, which will no longer be in effect for CY 2027.
This effectively means that current law requires -2.50% reduction in Medicare payment under the PFS compared to CY 2026. The CY 2027 qualifying APM conversion factor of $32.95 represents a projected decrease of $0.62 (-1.83%) from the current conversion factor of $33.57. Similarly, the CY 2027 nonqualifying APM conversion factor of $32.63 represents a projected decrease of $0.77 (-2.31%) from the current conversion factor of $33.40.
KX Modifier Thresholds
$2,540 for PT and SLP combined.
$2,540 for OT alone.
$3,000 for targeted review.
New SLP Codes
At the September 2025 CPT Editorial Panel meeting, CPT code 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual) was replaced with 10 new codes to report fluency disorder, speech sound production disorder, language comprehension and expression disorder, speech sound production disorder and language comprehension and expression disorder, and voice, upper airway dysfunction and/or resonance disorders.
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Code
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Description
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RVU
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92654
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Treatment of fluency disorder (eg, stuttering and cluttering), direct (one-on-one) patient contact; initial 30 minutes
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0.92
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92655
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Treatment of fluency disorder (eg, stuttering and cluttering), direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary service
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0.44
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92656
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(Treatment of speech sound production disorder (eg, articulation, phonological process, apraxia, dysarthria), direct (one-on-one) patient contact; initial 30 minutes
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0.90
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92657
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Treatment of speech sound production disorder (eg, articulation, phonological process, apraxia, dysarthria), direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary service
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.44
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92658
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Treatment of language comprehension and expression disorder (eg, receptive and expressive language), direct (one-on-one) patient contact; initial 30 minutes
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1.00
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92659
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Treatment of language comprehension and expression disorder (eg, receptive and expressive language), direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary service
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0.48
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92600
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Treatment of speech sound production disorder (eg, articulation, phonological process, apraxia, dysarthria) and language comprehension and expression disorder (eg, receptive and expressive language), direct (one-on-one) patient contact; initial 30 minutes
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1.00
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92661
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Treatment of speech sound production disorder (eg, articulation, phonological process, apraxia, dysarthria) and language comprehension and expression disorder (eg, receptive and expressive language), direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary service
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0.50
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92662
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Treatment of voice, upper airway dysfunction, and/or resonance disorders, direct (one-on-one) patient contact; initial 30 minutes
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0.98
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92663
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(Treatment of voice, upper airway dysfunction, and/or resonance disorders, direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary service
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0.48
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CMS finalized all 11 speech-language pathology treatment codes as always therapy (including the 10 new CPT codes and the revised CPT code 92508 that was previously designated as always therapy) and adding CPT codes 92654, 92656, 92658, 92660, and 92662 for the initial 30 minutes of the primary service to the list of codes that are subject to the therapy MPPR.
New SLP Pediatric G Code
G0903 - Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual; for the pediatric population age 21 and under.
RVU 1.30
Remote Monitoring
Established Patient Requirements
For CY 2027, CMS proposed to require that RTM services also be furnished only to established patients. CMS proposed this condition of payment because they believe that a practitioner with an established relationship with a patient would likely have had the opportunity to collect relevant patient history and conduct a physical exam, as appropriate.
As a result, the practitioner would possess information needed to understand the current medical status and needs of the patient prior to ordering RTM services to collect and analyze the patient's data and would be able to use the results of remote therapeutic monitoring to manage the patient under a specific treatment plan or therapy plan of care.
After consideration of public comments, CMS has finalized the requirement that RTM services be furnished only to established patients.
Initiating Visit Requirements
For CY 2027, CMS proposed that practitioners reporting RPM or RTM services must furnish a separately reportable initiating visit in association with the onset of RPM or RTM services, since these services require a level of care coordination that cannot be effective without appropriate evaluation of the patient's needs.
The initiating visit would also ensure the billing practitioner assesses the beneficiary to determine clinical appropriateness of RPM or RTM and provide an opportunity to obtain the required beneficiary consent to receive RPM or RTM services.
CMS proposed that RPM or RTM services must be initiated by the billing practitioner during a face-to-face (in-person or telehealth) visit. CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable under Medicare cannot be used as the visit for RPM or RTM initiation.
If RPM or RTM is not discussed with the patient at that visit, that visit cannot count as the initiating visit for RPM or RTM. The RPM or RTM initiating visit can be separately billed.
While RPM or RTM services must be initiated by the billing practitioner during a face-to-face (in-person or telehealth) visit, the initiating visit does not have to be for the sole purpose of discussing remote monitoring services. CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable under Medicare cannot be used as the visit for RPM or RTM initiation.
If RPM or RTM is not discussed with the patient at that visit, that visit cannot count as the initiating visit for RPM or RTM. At this time, CMS did not finalize any exemptions to initiating visit requirements, including for patients aligned to ACOs, as these services require a level of care coordination that cannot be effective without appropriate evaluation of the patient's needs. An initiating visit is the best way to ensure this evaluation is occurring.
Billing for RPM or RTM services may not begin until the initiating visit has been furnished. CMS did not finalize a restriction on the amount of time between the initiating visit and the activation of monitoring, as long as RPM or RTM is discussed with the patient at that visit.
To minimize beneficiary burden associated with this initiating visit requirement, CMS is allowing initiating visits to be furnished via telehealth. In addition, for the purposes of this policy, a beneficiary may be considered an established patient after they have met the initiating visit requirements.
CMS did not establish a definition of “onset” for RPM and RTM in this rule, however, we welcome ongoing feedback on this policy and may consider this additional information for future rulemaking.
Supervision Requirements
CMS proposed to only allow payment for RPM or RTM services when furnished by clinical staff employed by the practice. To count the time spent by clinical staff providing aspects of RPM or RTM services, the clinical staff must be a direct employee of the practitioner or the practitioner's practice.
This means that for the purposes of billing Medicare, beginning January 1, 2027, the RPM and RTM codes could not be billed in cases where the service is not performed by clinical staff of the billing practitioner and will not allow contracting out to third-party companies.
This does not mean the clinical staff must necessarily always be physically located within the practice, nor does it require that the beneficiary be on-site for the provision of remote monitoring services.
The time spent by clinical staff providing RPM or RTM services can be counted, provided that the clinical staff are under the general supervision of the billing practitioner, all other requirements of the “incident to” regulations at § 410.26 are met, and the clinical staff is a direct employee of the practitioner or the practitioner's practice.
Delayed for 2 years.
After consideration of public comments, we are finalizing that for the purposes of billing Medicare, beginning January 1, 2029, the RPM and RTM codes cannot be billed in cases where the service is not performed by clinical staff that is a direct employee of the practitioner or the practitioner's practice and contracting out to third-party companies will not be allowed after that time.
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Code
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Description
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98975
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); initial set-up and patient education on use of equipment
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98976
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 16-30 days in a 30-day period
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98977
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 16-30 days in a 30-day period
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98978
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 16-30 days in a 30-day period
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98979
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Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least 1 real-time interactive communication with the patient or caregiver during the calendar month; first 10 minutes
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98980
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Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
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98981
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Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
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98984
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 2-15 days in a 30-day period
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98985
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 2-15 days in a 30-day period
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98986
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Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 2-15 days in a 30-day period
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99091
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Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days
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99445
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Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial: device(s) supply with daily recording(s) or programmed alert(s) transmission, 2-15 days in a 30-day period
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99453
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Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
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99454
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Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, 16-30 days in a 30-day period
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99457
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Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
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99458
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Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)
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99470
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Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring 1 real-time interactive communication with the patient/caregiver during the calendar month; first 10 minutes
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99473
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Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration
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99474
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Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient
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MIPS
Measures Added
Quality #518: Functional Improvement for Patients with Neck Impairments
Percentage of patients aged 18 years and older with a neck impairment that met the risk-adjusted Predicted Moderate Clinical Improvement (P-MCI) on the PROMIS Pain Interference (PPI) or the alternative (legacy) patient-reported outcome measure (PROM), the Neck Disability Index (NDI).
Quality #519: Functional Improvement for Patients with Upper Extremity Impairments
Percentage of patients aged 18 years and older with an upper extremity impairment that met the risk-adjusted Predicted Moderate Clinical Improvement (P-MCI) on the PROMIS Upper Extremity (PUE) or the alternative (legacy) patient-reported outcome measure (PROM), the Quick Disabilities of the Arm, Shoulder, & Hand (QDASH).
Quality #520: Functional Improvement for Patients with Back Impairments
Percentage of patients aged 18 years and older with a back impairment that met the risk-adjusted Predicted Moderate Clinical Improvement (P-MCI) on the PROMIS Pain Interference (PPI) or the alternative (legacy) patient-reported outcome measure (PROM), the Modified Low Back Disability Questionnaire (MDQ).
Quality #521: Functional Improvement for Patients with Lower Extremity Impairments
Percentage of patients aged 18 years and older with a lower extremity impairment—not including knee impairments—that met the risk-adjusted Predicted Moderate Clinical Improvement (P-MCI) on the PROMIS Physical Function (PPF) or alternative (legacy) patient-reported outcome measure (PROM), the Lower Extremity Functional Scale (LEFS).
Quality #522: Functional Improvement for Patients with Knee Impairments
Percentage of patients aged 18 years and older with a knee impairment that met the risk-adjusted Predicted Moderate Clinical Improvement (P-MCI) on the PROMIS Physical Function (PPF) or the alternative (legacy) patient-reported outcome measure (PROM), the Knee Outcome Survey (KOS).
Measures Removed
Quality # 217: Functional Status Change for Patients with Knee Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with knee impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #218: Functional Status Change for Patients with Hip Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with hip impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with foot, ankle or lower leg impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #220: Functional Status Change for Patients with Low Back Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with low back impairments. The change in FS is assessed using the FOTO Low Back FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #221: Functional Status Change for Patients with Shoulder Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the FOTO Elbow/Wrist/Hand FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Quality #478 Functional Status Change for Patients with Neck Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
