MEDICARE ADVANTAGE
STATUS: FINAL
CMS released the CY 2027 Medicare Advantage and Part D Rate Announcement on April 6, 2026. For CY 2027, CMS will continue using the 2024 CMS HCC risk adjustment model rather than implementing the alternative model discussed in the CY 2027 Advance Notice. Beginning in CY 2027, diagnoses reported from audio only encounters will be excluded from Medicare Advantage risk score calculation. CMS will also exclude diagnoses submitted through unlinked chart review records when the diagnosis cannot be associated with a specific beneficiary encounter, subject to limited exceptions described by CMS.
CMS Reference:
2027 Medicare Advantage and Part D Rate Announcement
STAR RATINGS
STATUS: FINAL
CMS finalized changes to the Medicare Advantage and Part D Star Ratings program as part of the Contract Year 2027 Final Rule. The final rule includes revisions to Star Ratings measures and methodology, including changes intended to place greater emphasis on clinical care, outcomes, patient experience, and access.
CMS Reference:
Contract Year 2027 Medicare Advantage and Part D Final Rule
Medicare Shared Savings Program & ACOs
STATUS: PROPOSED
CMS released proposed changes to the Medicare Shared Savings Program (MSSP) as part of the CY 2027 Medicare Physician Fee Schedule Proposed Rule. The proposals include changes to ACO financial methodology, benchmarking, quality reporting, and other program requirements. CMS is also proposing policies addressing benchmark rebasing and participation in two sided risk arrangements. These provisions remain proposed and may change before publication of the final rule.
CMS Reference:
CY 2027 Medicare Shared Savings Program Proposed Changes
Medicare Physician Fee Schedule
STATUS: PROPOSED
CMS released the CY 2027 Medicare Physician Fee Schedule Proposed Rule on July 14, 2026. CMS proposes separate 2027 conversion factors for qualifying Alternative Payment Model participants and practitioners who are not qualifying APM participants.
The proposed conversion factors are:
Qualifying APM Participants: $33.17
Non Qualifying APM Participants: $32.84
These amounts are proposed and are not final CY 2027 Medicare payment rates.
The public comment period is scheduled to close September 14, 2026.
CMS Reference:
CY 2027 Medicare Physician Fee Schedule Proposed Rule
Hospital Outpatient & ASC Payment
STATUS: PROPOSED
CMS released the CY 2027 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule. CMS proposes a 2.4% payment update for hospitals that meet applicable Hospital Outpatient Quality Reporting requirements.
CMS also proposes a 2.4% payment update for ASCs that meet applicable quality reporting requirements. The proposed rule also addresses 340B acquired drugs, partial hospitalization programs, intensive outpatient programs, hospital price transparency, and other outpatient payment policies. These provisions remain proposed pending publication of the CY 2027 final rule.
CMS Reference:
CY 2027 OPPS and ASC Proposed Rule
Hospital Outpatient Prior Authorization
STATUS: PROPOSED
CMS proposes expanding Medicare prior authorization requirements for certain hospital outpatient department services. The CY 2027 OPPS proposed rule includes the addition of prior authorization requirements for eight botulinum toxin injection codes. This provision is proposed and is not currently a final Medicare requirement.
CMS Reference:
CY 2027 OPPS and ASC Proposed Rule
Outpatient & ASC Quality Reporting
STATUS: PROPOSED
CMS proposes changes to the Hospital Outpatient Quality Reporting (OQR) Program and Ambulatory Surgical Center Quality Reporting (ASCQR) Program for CY 2027. CMS also proposes changes to the methodology used to calculate the Overall Hospital Quality Star Rating, including increased emphasis on the Safety of Care measure group. These provisions remain proposed.
CMS Reference:
CY 2027 OPPS and ASC Proposed Rule
Medicare Billing & Coding
STATUS: FINAL
The FY 2027 ICD-10 code set becomes effective October 1, 2026, and applies through September 30, 2027. The FY 2027 release includes new, revised, and deleted diagnosis codes and updated official coding guidance.
CMS Reference:
CMS ICD-10-CM Codes
October 2026 HCPCS Update
STATUS: FINAL
CMS issued the October 2026 HCPCS Quarterly Update, effective October 1, 2026. The quarterly update includes new, revised, and discontinued HCPCS codes applicable to Medicare claims.
CMS Reference:
October 2026 HCPCS Quarterly Update
Medicare NCCI Edits
STATUS: FINAL
CMS NCCI Procedure to Procedure Edit Version 32.3 becomes effective October 1, 2026.
The quarterly release updates Medicare Procedure to Procedure coding edits used in claims processing.
CMS Reference:
CMS National Correct Coding Initiative
RHC & FQHC Telehealth Billing
STATUS: FINAL
Beginning October 1, 2026, Rural Health Clinics and Federally Qualified Health Centers will report the individual CPT or HCPCS code describing an applicable distant site telehealth service rather than HCPCS code G2025. CMS instructions also address the applicable revenue code and use of Modifier 93 for qualifying synchronous audio only services and Modifier 95 for qualifying synchronous audio video services.
CMS Reference:
CMS RHC & FQHC Distant-Site Telehealth Billing Update
Health Plan Marketplace & Risk Adjustment
STATUS: FINAL
CMS issued the HHS Notice of Benefit and Payment Parameters for 2027 Final Rule on May 15, 2026. The final rule establishes 2027 policies for the Health Insurance Exchanges and includes changes involving the HHS operated risk adjustment program, Risk Adjustment Data Validation, qualified health plans, provider access, quality requirements, and Exchange operations. The final rule became effective July 20, 2026.
CMS Reference:
HHS Notice of Benefit and Payment Parameters for 2027 Final Rule
About This Update
STRUŌ provides periodic updates on CMS policies affecting healthcare operations, revenue cycle management, reimbursement, medical coding, clinical documentation, risk adjustment, quality programs, value based care, and health plan operations.
Disclaimer
This publication is provided by STRUŌ for general informational and educational purposes only. It does not constitute legal, regulatory, compliance, coding, billing, reimbursement, or financial advice. Proposed rules summarized in this publication have not been finalized and may be revised, withdrawn, or modified by CMS before implementation. Final rules and other CMS guidance may also be subject to subsequent clarification or modification. Readers should refer to the official CMS publications linked within this update and other applicable federal, state, payer, and Medicare Administrative Contractor requirements for current guidance. Reference to CMS, HHS, Medicare, or other government programs does not constitute or imply endorsement of STRUŌ by the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services, or any other government agency.
Source: Centers for Medicare & Medicaid Services (CMS)
Information current as of August 11, 2026.
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