The Rheum Advocate: December 11, 2025

ACR Meets with Congress: 2026 Physician Payments, In-Office Care, and Telehealth Access Are on the Line

This week the ACR briefed Congress on proposals in the 2026 Physician Fee Schedule changes, including a new efficiency adjustment to better value in-office care. In January, the ACR will work to help prevent another shutdown, as telehealth and other services face disruption when current funding expires on February 1.

ACR Educates Congress on the In-Office Care Adjustment for Rheumatologists

Following the finalization of the 2026 Medicare Physician Fee Schedule (MPFS), the ACR is participating in targeted meetings on Capitol Hill alongside coalition partners in support of CMS’ proposed efficiency adjustment, set to take effect on January 1, 2026. The goal of this proposal is to better reflect the actual time spent on the core patient care component of a service, accounting for efficiencies gained over time. This adjustment will not impact evaluation and management codes and other time-based codes.

Key Points on the 2026 Medicare Physician Fee Schedule (MPFS) Efficiency Adjustment

• Effective Date: January 1, 2026
• Purpose: To reflect actual time spent on core patient care components of a service and account for efficiencies gained over time.
• What’s Affected:
  • Non-time-based CPT codes
  • Results in -2.5% reduction in physician time RVU and intra-service time estimates
• Does NOT affect:
  • Evaluation & Management (E/M) codes
  • Other time-based codes
  • Malpractice liability RVU
  • Practice expense RVU
  • Pre- or post-service time estimates
• Impact on Rheumatologists:
  • Most rheumatology services are time-based (e.g., CPT 96365, 99358)
  • Rebalancing toward time-intensive, cognitive services (clinical judgment, decision-making, and problem-solving), rather than performing a physical procedure
  • May benefit rheumatologists and patients
• Important Clarifications:
  • Adjustment does not require less time performing procedures
  • Payment reflects current resource use, not reduced effort
  • Many codes used daily by rheumatologists have not been updated in over a decade, leading to undervaluation
• ACR’s Position: Supports CMS efforts to ensure rheumatologic care is accurately valued and reimbursed
  • This efficiency adjustment is a step toward fairer payment policies

Contact your lawmakers to allow the efficiency adjustment to take effect in January and encourage them to pursue long-term, sustainable Medicare reimbursement reforms.
Take action >

Government Funding Deadline Looms: Telehealth Access and ACR Priorities at Risk

Congress faces another rapidly approaching government funding deadline. The bill that was passed to re-open the government last month provides funding through January 30, 2026. That means that once again telehealth and many other ACR priorities could be at risk, without Congressional action.

This deadline looms in the background of a Senate vote on a three-year extension of the Affordable Care Act premium tax credits, which expire at the end of the year. The bill likely lacks the required 60 votes to pass the Senate, meaning that the next opportunity for Congress to act will be through legislation to avoid another shutdown on January 30, 2026.

The ACR will continue to advocate for a permanent extension of telehealth flexibilities and will urge Congress to prioritize stabilizing access to this critical component of providing rheumatologic care. You can join these efforts via the Legislative Action Center >

Make an Impact Before Year End: Support RheumPAC Today!

RheumPAC events empower rheumatologists to amplify their voice in Washington, D.C., ensuring policies that protect patient access to care and support the future of rheumatology. These events are co-hosted with other medical specialties and focus on current healthcare policy discussions. By connecting ACR advocacy staff with key lawmakers in this setting, these events help advance ACR’s priorities, strengthen practice sustainability, and improve outcomes for patients nationwide. See your donations at work from July–November:

• Lunch for Senator John Boozman – Arkansas (R)
• Breakfast for Representative Don Bacon – Nebraska (R)
• Lunch for Representative Claudia Tenney – New York (R)
• Reception for Representative Tom Suozzi – New York (D)
• Lunch for Senator Mike Crapo – Idaho (R)
• Lunch for Representative Herb Conaway, MD – New Jersey (D)
• Lunch for Senator Bill Cassidy – Louisiana (R)
• Reception Senator Ben Ray Lujan – New Mexico (D)
• Lunch for Chairman Jason Smith – Missouri (R)
• Reception for Representative Steven Horsford – Nevada (D)
• Lunch for Representative Angie Craig – Minnesota (D)
• Lunch for Ranking Member Rosa DeLauro – Connecticut (D)
• Lunch for Senator John Barrasso – Wyoming (R)
• Reception for Representative Kim Schrier, MD – Washington (D)

As the year closes, your contribution to RheumPAC helps ensure rheumatology’s voice is heard. Don’t miss the chance to make a difference—give before December 31! Go to rheumatology.org/donate and select RheumPAC as your contribution option.

How Can You Take Action?

Contact your members of Congress today and urge them to support science-based vaccine recommendations and oppose efforts that threaten patient access to vaccines.

Register for ACR advocacy office hours, where you have access to our congressional, regulatory, state, and private payer advocacy staff, so any question or concern you have will find the right ears.

Meet Amanda Myers, MD, FACR, the Chair of ACR’s Government Affairs Committee (GAC): Leading Advocacy for Rheumatology

As the newly appointed Chair of the ACR Government Affairs Committee (GAC), Amanda Myers, MD, FACR, will guide the College’s legislative and regulatory advocacy efforts, championing policies that improve patient access to care, strengthen the rheumatology workforce, and advance research funding for rheumatic diseases. Dr. Myers is a highly respected rheumatologist with more than two decades of experience in private and hospital-based practice at Endeavor Health in Evanston, Illinois, where she is known for her patient-centered approach. Dr. Myers emphasizes shared decision-making and education, ensuring that individuals feel empowered and supported in managing chronic disease.

Dr. Myers’ dedication to her patients and her profession exemplifies the values of the ACR. As GAC chair, her vision combines clinical insight with strategic policy leadership, ensuring that the voice of rheumatology is heard at every level of government. Her appointment as chair marks an exciting chapter for the organization and for the future of rheumatology advocacy. She brings experience from the ACR’s Board of Directors and a previous tenure on GAC and other ACR committees.

Dr. Myers carries her clinical care priorities into her advocacy. As a member of GAC she spearheaded a grassroots working group that led a rheumatology member-to-member community outreach project, which encouraged members in districts with lawmakers that have not worked with the ACR to establish relationships with those offices.

Beyond her clinical work, Dr. Myers has demonstrated exceptional leadership within the rheumatology community. Her commitment to advocacy is evident through her work leading grassroots engagement initiatives and representing rheumatology in national policy discussions, including Medicare drug pricing negotiations. Dr. Myers represented the ACR in a CMS townhall in April 2025, testifying on the need to make crucial treatments more accessible to patients under Medicare.

The first endeavor of GAC under Dr. Myers' leadership will be an overhaul of the ACR health policy statements (HPS). These are the official formal public policy positions of the College, which comprehensively reflect the policies impacting the practice of rheumatology. The HPS serve to empower the ACR to react to public policy with written and approved positions and statements of the ACR behind it. Excerpts have been used to inform members of Congress, regulatory entities, and partner organizations of ACR policy positions and recommendations. As so much of the healthcare policy landscape has changed in 2025, Dr. Myers is taking care to separate each section for specific review and updating, as well as making additions to ensure this important document is up to date going into 2026.

A graduate of Indiana University School of Medicine, Dr. Myers completed her residency and fellowship training in internal medicine and rheumatology at Emory University, earning board certification in both specialties.

ACR Pushes Back Against Commercial Payer Downcoding of E/M Claims

The ACR continues to oppose commercial payer policies that automatically downcode level 4 and 5 Evaluation and Management (E/M) claims. These policies reduce appropriate payment for rheumatology services and increase administrative burden on practices forced to review and appeal downcoded claims.

Inappropriate reimbursement cuts undermine patient access to timely care. The ACR is actively engaging with two major payers—Aetna and Cigna—to address recent E/M downcoding policies.

Aetna

• Aetna launched its Claim and Code Review Program in 12 states in 2022 and expanded it to all commercial states (except Louisiana) in March 2025.
• Level 4 and 5 E/M claims are now flagged for prepayment review and may be reimbursed at lower levels.
• Practices generally remain in the program for one year, but can seek early removal by successfully appealing at least 75% of downcoded claims.
• The ACR continues discussions with Aetna leaders regarding inappropriate payment reductions and practice burden.

Cigna

• Cigna implemented its Evaluation and Management Coding and Accuracy policy on October 1, 2025.
• E/M codes 99204–99205, 99214–99215, and 99244–99245 are reviewed and may be downcoded by one level.
• The ACR has contacted Cigna and joined multi-specialty sign-on letters opposing the policy.

The ACR strongly opposes these policies and the escalating use of artificial intelligence in claims review without adequate human oversight. The College urges payers to rely on trained professional coders to maintain integrity in claims processing.

Protecting Your Practice

To help prevent unnecessary downcoding, rheumatology practices should:

• Use the most specific ICD-10 codes available; avoid unspecified codes [AC2.1][TA2.2] when possible.
• Document thoroughly to support the billed level of service.
• Confirm that medical necessity is clearly met and described in the record.
• Review all remittance advice and EOBs for evidence of downcoding.

Practices are encouraged to verify patient benefits before each visit, as coverage policies may change.

Has your practice experienced E/M downcoding? Contact practice@rheumatology.org to share your experience or request assistance with claims review.

Get Ahead of 2026: Essential Coding Prep to Safeguard Your Practice

As 2025 ends, it’s important that rheumatology practices begin preparing for the coding, billing, and documentation changes that will take effect in 2026. With ongoing shifts in payment policy, evolving CPT and ICD-10 guidance, and heightened compliance for documentation, the end of the year is the ideal time to assess workflows, educate staff, and ensure your practice enters 2026 on a strong note.

Strengthening Documentation Practices Before January 1

With the recent downcoding practices by insurance companies, like Cigna and Aetna, that reduce provider reimbursement, high-quality documentation is essential for compliance in 2026.

Key points to address now:

• Audit a sample of 2025 charts to pinpoint common deficiencies.
• Confirm time-based billing reflects valid face-to-face or non–face-to-face activities allowed under CPT.
• Validate that procedural notes (joint injections, aspirations, ultrasound-guided procedures) include:
  • Laterality
  • Anatomical location
  • Needle guidance documentation
  • Medical necessity rationale

A clean documentation foundation heading into 2026 will protect your practice from denials and recoupments.

Evaluate Coding Accuracy Now

Coding errors are the primary cause of claim denials and underpayments. The end of the year is the ideal time to identify patterns of undercoding or missed charges. So, it is important to verify:

• Charges and coding align with actual services performed.
• Providers and staff are consistently applying correct modifier usage (e.g., 25, 59, RT/LT, 51).
• Drugs billed under HCPCS codes accurately reflect units, wastage, and inventory reconciliation.
• Prior authorization rules for specialty medications are updated and documented.

A strong revenue cycle review now can prevent cash flow disruptions for the next year.

Reassess Medicare and Commercial Payer Policies

Medicare and commercial payers often adopt policy updates each January. It is important for practices to:

• Review updates to each plan’s Local Coverage Determinations (LCDs) for rheumatology-related services, such as:
  • Ultrasound
  • DXA scans
  • Infusion therapies
  • Laboratory testing

• Confirm the 2026 Medicare Physician Fee Schedule (MPFS) changes, including:
  • RVU adjustments
  • Any changes to drug administration reimbursement
  • Care management or remote monitoring updates

This payer-specific review ensures your practice avoids claim denials in the first quarter of 2026.

Train and Prepare the Entire Team

The ACR offers a wide range of rheumatology-specific educational tools designed to ensure your team stays informed, compliant, and aligned with national standards. The resources include:

• Coding and billing workshops
• ACR’s coding guidance documents for E/M, ICD-10, incident-to, infusions, and ultrasound
• Auditing review and workshops
• Insurance denials and letters
• Lunch and learn coding sessions for training and updates

Preparing now for the 2026 coding year will help protect your practice from revenue disruptions, claim denials, and compliance issues. By reviewing coding updates, strengthening documentation, monitoring payer changes, and engaging with ACR’s coding resources, your team will be well-positioned for a successful year ahead, as staying compliant and accurate has never been more critical.

For questions on the ACR resources or for assistance with billing, coding, and/or claim denials, contact the ACR practice management team at practice@rheumatology.org.