CMS 2026 Fee Schedule: Solo Therapists Get a Flat Rate, Integrated Practices Get +3.77%
CMS 2026 Fee Schedule: Solo Therapists Get a Flat Rate, Integrated Practices Get +3.77%
What's happening
- Conversion factor rose +3.77% for APM-participating practices, but is flat for solo practitioners (LCSWs, LPCs, psychologists) — a real-value cut after inflation
- Old Collaborative Care billing codes (CPT 99492–99494) were retired January 1, 2026 and replaced by G-codes G0568, G0569, G0570 — claims using old codes are now denied
- LMFTs and LMHCs, independently billable under Medicare since 2024 at 75% of psychologist rates, now operate within the same flat-rate environment as LCSWs
- Digital Mental Health Treatment (DMHT) device reimbursement expanded — FDA-cleared prescription digital therapeutics (like Rejoyn) now have dedicated CPT pathways alongside new prescribing and monitoring codes
Why now
CMS issued final rule CMS-1807-F in late 2025, effective January 1, 2026. It is the most consequential behavioral health billing update since the 2024 LMHC/LMFT Medicare expansion. The coding change is not optional — non-updated claims are being denied. And the split conversion factor is quietly reshaping who wins financially in the US mental health system.
What the data shows
For solo therapists, the arithmetic is blunt. Medicare pays approximately $150 for CPT 90837 (53-minute individual therapy). The flat conversion factor means that rate is unchanged from 2025 in nominal dollars — and effectively lower in real terms given CPI. For a clinician billing 800–1,000 Medicare sessions per year, that is a $0 nominal change but a $3,000–5,000 real purchasing power loss relative to 2024 rates.
Psychiatrists and integrated primary care practices in Alternative Payment Models see the opposite: a +3.77% conversion factor increase across E/M codes, medication management, and the new G0568–G0570 Collaborative Care codes. CMS estimates a psychiatrist billing 1,500 Medicare encounters annually gains approximately $4,000–$7,000 in additional annual revenue.
The structural message: CMS is rewarding system integration and penalizing — in real terms — stand-alone outpatient psychotherapy. Practices in qualifying APMs (Primary Care First, certain ACO tracks) collect more for the same service than identical practices outside those models.
Health Behavior Assessment and Intervention (HBAI) codes 96156–96171 also received updated time thresholds and documentation requirements. These codes, used when behavioral factors affect medical conditions (medication adherence, chronic pain adjustment), are relevant for psychologists embedded in medical settings.
What this means for you
If you bill Medicare and are not in an APM, your rates have not moved. Your costs have. The decision point is whether to pursue APM participation — specifically the Behavioral Health track of Primary Care First — or whether to reduce Medicare exposure in your caseload in favor of commercial payers, which benchmark at 120–200% of Medicare rates for the same codes.
The retired CoCM codes (99492–99494) are an immediate compliance issue. If your practice uses Collaborative Care billing, claims submitted with old codes for dates of service after December 31, 2025 are being denied. Update your fee schedule templates, charge capture systems, and clearinghouse configurations to G0568–G0570 now.
For LMFTs and LMHCs: the 75%-of-psychologist-rate structure means your Medicare 90837 reimbursement is approximately $112 vs. $150 for a psychologist in the same setting. Same flat trajectory. The credential differential does not disappear under Medicare.
Pull quote: CMS's split conversion factor encodes a strategic preference — integration over solo practice — that will compound year over year unless Congress changes the formula.
Caveats: Specific reimbursement rates vary by locality; the $150/90837 figure is a national midpoint, not a guaranteed floor. APM qualification requirements and timelines vary. The DMHT expansion creates reimbursement pathways but does not require prescribing digital therapeutics — it is an option, not a mandate.
Tags: Medicare, CMS 2026, physician fee schedule, reimbursement, psychotherapy billing, Collaborative Care, DMHT, private practice
CMS's split conversion factor encodes a strategic preference — integration over solo practice — that will compound year over year unless Congress changes the formula.