The march toward individual-level, digital quality reporting.
By Connor Knapp, Director of Sales, MD Revolution, a CoachCare company
The 2026 Final Rule has already generated significant analysis, praise, and criticism. While it’s easy to over-index on individual updates to CMS’s Physician Fee Schedule (PFS), the goal of this article is to “see the forest” and tie the pieces together to understand CMS’s overall direction and strategy — not just its tactical adjustments.
If you only skim one paragraph: 2026 is the year CMS stitches together three signals into one clear direction:
- Quality moves from sample-based reporting to individual-level, digital submission.
- Remote care gets more right-sized RPM codes, including reimbursement for months with fewer monitoring days.
- The Ambulatory Specialty Model (ASM) may define the next decade of cardiovascular care and pain management.
First things first: how about some applause for the team at CMS?
Before diving in, it’s worth acknowledging the people behind the 2026 PFS Final Rule. Every year, CMS staff deliver complex, consequential policy updates under enormous pressure. Many in the industry — including us — are grateful for the timely publication of these results, which are in essence the culmination of an all hands on deck, 24/7/365 endeavor that is undertaken year after year after year.
The Big Strategic Shift: Digital Quality Becomes Individual-Level
This is the part of the rule most analyses underplayed — and arguably the most important directional signal CMS has sent since the introduction of MIPS.
CMS is steadily replacing sample chart abstraction with unique patient‑level, computable submissions and FHIR‑aligned digital measures. While stability will always be a priority at this stage of CMS’s “march to value” and this year was no different, the CMS team advanced key pieces on the board: individual‑level QP determinations for Advanced APMs and continued alignment toward digital quality measures (dQMs). Pair this with QRDA‑I (patient‑level) standards and the direction is unmistakable: your denominator becomes your whole eligible population.
- APP Plus replaces Web Interface sampling. This is a shift already in motion since 2025 and reinforced in 2026 via measure set updates and scoring policy.
- Individual-level determinations replace group abstractions and QRDA-I becomes the center of gravity for eCQMs.. CMS added individual‑level QP determinations for Advanced APMs, and its QRDA standards continue to center patient‑level (QRDA‑I) submissions for eCQMs. This is foundational to individual‑based reporting.
- Digital Quality Measures (dQMs) is looking like CMS’s end game. CMS’s dQM Strategic Roadmap aims to transition quality measures to digital specifications (FHIR, CQL) that can ingest data from interoperable sources – not just EHRs (think care management platforms, FDA validated home devices, and IOT devices). 2026 QPP doesn’t “flip the switch,” but the rails are laid.
For digital health leaders:
You’re officially on the clock to ensure your FHIR pipelines, identity resolution, and device data ingestion support patient-level, audit-ready quality reporting.
Translation: Data plumbing matters. You need identity resolution, FHIR‑ready pipelines, and the ability to ingest EHR + device + patient‑generated data so measure logic can run at the patient level and be auditable for submission.
The denominator has evolved from a 248-patient sample to your entire population, with requirements moving beyond EHR data toward a FHIR-ready layer that integrates patient-generated and IoT data where allowed.
Forest View: As organizations iterate internal data infrastructure, they must begin enriching their data with tech-enabled, reimbursable service lines like RPM, CCM, PCM, APCM, INR Monitoring, CGM Monitoring, Virtual Cardiac Rehab, and Virtual Obesity Management.
RPM “Right-Sizing”: New CPT Codes (99445 & 99470)
CMS has long heard feedback on the rigidity of:
- 99454 (device supply — requires 16+ days of physiologic data)
- 99457 (first 20 minutes of RPM management)
To reduce friction and expand appropriate reimbursement, CMS has created two additional codes:
- CPT 99445: device supply when data are recorded/transmitted for 2–15 days
- CPT 99470: the first 10 minutes of RPM management with at least one real-time interactive communication
These pair with the existing 16–30 day supply and 20-minute management codes. Notably, the new codes are non-additive with their original counterparts.
Translation: Months with 5–10 days of vitals can now be reimbursed, reducing waste and better reflecting real clinical workflows.
Forest View: CMS continues to strengthen RPM as a core service line. These new codes acknowledge that clinicians deliver meaningful remote care even in lower-data months — particularly in specialties such as oncology and obesity, where RPM, CCM, and PCM adoption has historically been low but highly valuable.
Ambulatory Specialty Model (ASM): Value-based care grows up for specialists
While most headlines around the Final Rule center on telehealth and fee schedule adjustments, the ASM may be the most consequential change for specialty care over the next decade.
CMS is moving ahead with a mandatory, five-year model beginning January 1, 2027, focused on heart failure and low back pain across targeted regions (core-based statistical areas and metro divisions).
What CMS finalized:
- Mandatory participation for eligible specialists with sufficient volume in selected geographies (cardiology for HF; anesthesiology, pain, ortho, neurosurgery, PM&R for LBP).
- A five-year model (2027–2031) aimed at improving upstream management to reduce avoidable hospitalizations and procedures.
- Advanced APM-style incentives: specialists are compared to peers on cost and quality, with positive, neutral, or negative adjustments to Part B claims.
- MVP alignment: A design that borrows heavily from MIPS Value Pathways (MVPs), ASM leverages measures from existing heart disease and musculoskeletal MVPs to keep expectations consistent across QPP and CMMI.
- CMS will publish an initial list of participants in early 2026, with finalization later in the year so specialists have time to prepare.
Translation: CMS has been explicit that ASM can coexist with other models and MSSP participation. Specialists can stay in ACOs while also being directly accountable for HF and back pain outcomes. That era of “this is the ACO’s problem” is over.
Forest View: The Ambulatory Specialty Model may be V1 of what becomes the dominant driver of cardiovascular care transformation in the coming decade.
Conversion Factor “Efficiency Adjustment”
For 2026, CMS finalized two PFS conversion factors:
- $33.57 for qualifying APM QPs (+3.77%)
- $33.40 for non-QPs (+3.26%)
CMS also finalized a -2.5% efficiency adjustment to work RVUs for non-time-based services. (E/M, care management, behavioral health, telehealth-listed services, and maternity global codes are exempt.)
Translation: Longitudinal, team-based time remains protected; procedural codes may face gradual downward pressure.Forest View: CMS continues its march toward care pathways that prioritize patient-centric, team-based, long-term management over procedural throughput.
Fraud, Waste & Abuse (FWA): Skin Substitutes Join the Crackdown
First DME Catheters, now Skin Substitutes… are VBC models worth it for the FWA flagging alone?
Medicare spending on skin substitutes grew from $252M in 2019 to $10B in 2024.
CMS will now:
- Pay skin substitutes as incident-to supplies
- Align categorization to FDA status
- Implement a single blended rate (~$127.28) in 2026, ahead of more granular rates later
This aims squarely at notorious pricing abuse and rate gaming. Good news for VBC participants who have been cross‑subsidizing outliers.
Translation: The game is up for skin substitute manufacturers.
Forest View: There is a long history of FWA occurring when loopholes in the regulations are exposed. As VBC models evolve, TCOC vigilance and FWA analytics will evolve with them. CMS and OIG detection and action will continue to accelerate — a huge savings for taxpayers and value-based participants who have been subsidizing outliers.
RHCs & FQHCs/CHCs: The Unbundling Continues
CMS will move Community Health Centers (CHCs) from consolidated G-codes (G0512, G0071) to reporting the underlying codes starting January 1, 2026. This is in the interest of transparency and enabling more precise revenue capture. CMS also extends G2025 through Dec 31, 2026 for non‑behavioral telehealth visits.
CHCs can adopt the APCM BHI/CoCM add‑ons finalized under the PFS – useful for integrating behavioral health into chronic care workflows without duplicative documentation.
Translation: CMS is getting CHCs up to date with the rest of the ambulatory delivery sector when it comes to Remote Care delivery, billing, and reporting.
Forest View: This is the last bit of sunsetting for the investigational G codes that CMS initially rolled out years ago to “test” remote monitoring and care management programs. The signal here is that Remote Care passed those tests and is now a mainstay on the PFS.
Closing Thoughts
This rule doesn’t make splashy headlines — but it tilts the industry in a decisive direction:
The future CMS is building is one where robust, patient‑level digital will be table stakes to keep up with ever evolving standards of care and quality reporting, with payment reinforcing time spent coordinating and preventing (not just performing).
For healthcare delivery leaders:
2026 is the year to finalize data infrastructure, identity matching, device data capture, and flexible “click-and-mortar” care pathways.
About the Author
Connor Knapp is a digital health and value-based care strategist, currently serving as Director of Sales for the East Coast & Midwest at MD Revolution: A CoachCare Company. He works with health systems, ambulatory specialty groups, and Community Health Centers to architect and scale remote care service lines aligned with evolving CMS policy, digital quality reporting, and modern reimbursement frameworks. His work centers on integrating RPM, CCM, and FHIR-enabled data infrastructure into sustainable clinical operations.
Connor previously served as CEO/Founder of Sterling Heart Care and CEO of Altor Safety, leading teams through clinical expansion, operational transformation, and high-growth environments. Earlier in his career, he spent five years as a professional ice hockey player — experience that shaped his approach to resilience, leadership, and high-performance execution in healthcare.
