🚨 Medicare 2025–2026: What Doctors Need to Know Before October
As we move toward October 2025, several Medicare changes are set to reshape how physicians bill, document, and deliver care. While many of these adjustments began in 2025, their real impact hits this fall—and some could dramatically affect your reimbursement strategy.
Let’s break down what’s coming, specialty by specialty.
🩺 The Big Picture: What’s Changing in Medicare
Telehealth flexibilities expire on September 30, 2025 unless Congress acts.
After that, most non-behavioral telehealth services will once again be limited to rural “originating sites,” with home-based and audio-only visits restricted.
The 2025 Physician Fee Schedule (PFS) cut reimbursement by 2.83%, setting a lower baseline for 2026 unless reversed.
Prior authorization will expand in Ambulatory Surgical Centers (ASCs) starting late 2025, increasing administrative workload.
Ongoing quarterly CMS updates—including in October 2025—will introduce new CPT codes, status changes, and documentation rules.
⚕️ For Surgeons & Trauma Specialists
Postoperative care billing gets a revamp.
CMS clarified how global surgical packages work when postoperative care is shared. Expect greater scrutiny and more explicit use of modifiers -54/-55 to distinguish surgical vs. postop management.
Global period compliance.
When someone other than the operating surgeon handles follow-ups, the documentation must clearly note the transfer of care to support the postoperative add-on code.
Conversion-factor pressure.
The 2025 rate reduction stays in effect through Q4 2025 and into 2026. Trauma and general-surgery practices will need to balance efficiency with detailed, compliant E/M and procedure documentation to avoid underpayment.
Tip: Review how your E/M documentation supports 99231-99233 and 99291 critical-care billing, especially when shared among group providers.
đź©ą For Primary Care & Internal Medicine
Lower reimbursement remains the baseline.
The 2.83% PFS cut hits primary-care services hardest, but CMS added new opportunities to offset it.
Caregiver-training codes.
New G-codes for training family caregivers (effective 2025) can enhance both care quality and revenue if implemented properly.
ACO rule updates.
The Medicare Shared Savings Program (MSSP) now allows more flexible participation models and equity adjustments. Practices in ACOs should review 2025 quality and benchmark changes now.
Tip: Integrate caregiver-training and chronic-care-management billing into your schedule templates before October to capture new reimbursements.
🧠For Psychiatry & Behavioral Health
Telehealth stays strong.
Behavioral-health telehealth—including home-based and audio-only sessions—continues permanently under Medicare. The next potential in-person visit requirement for RHCs/FQHCs is delayed until Jan 1, 2026.
More billable clinicians.
Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) can now bill Medicare directly at 75% of the psychologist rate, widening your staffing options.
Tip: Keep tele-BH operations running as usual—but ensure all MFTs and MHCs are enrolled and credentialed under your Tax ID before October.
⚖️ What Everyone Should Watch
Telehealth “cliff.”
For non-behavioral care, remote visits from home may no longer be billable after September 30, 2025. Review your scheduling mix and start transitioning patients to in-person where needed.
Split/shared E/M visits.
CMS continues to use the “substantive portion” rule (aligned with CPT), with modifier FS required. Hospital and ICU teams must be precise about who provides the substantive portion of care.
2026 PFS proposal already out.
CMS released the 2026 proposed rule in July 2025, hinting at even stronger pushes toward value-based care and outcome-linked reimbursement.
🧠How Practices Should Prepare
Reassess telehealth strategy.
Plan for a possible rollback unless Congress extends flexibilities.
Update coding workflows.
Integrate Q4 2025 PFS database updates into your EHR and templates.
Audit documentation.
Ensure surgical and E/M notes explicitly define transfer of care, complexity, and time.
Educate your teams.
Train billers and providers on new codes, modifiers, and compliance triggers before Q4 2025.
Track specialty-specific advocacy.
Join AMA and specialty-society alerts—Congressional action could still delay or modify these rules.
đź’ˇ Bottom Line
October 2025 marks a turning point for Medicare billing. The combination of expiring telehealth flexibilities, fee schedule cuts, and expanded prior authorization means practices must adapt quickly to avoid lost revenue.
Whether you’re managing trauma cases, primary care visits, or behavioral health sessions—staying proactive with coding, documentation, and compliance is the key to thriving under the 2025-2026 Medicare landscape.