Medicare will pay a single national rate for proton therapy for the first time under CMS’ final 2027 physician fee schedule, released Nov. 4.
The rule, which takes effect Jan. 1, also raises payments for 3D conformal and intensity-modulated radiation treatments and changes how Medicare pays for AI tools that analyze cancer pathology.
Here are 12 things cancer leaders need to know from the rule:
- CMS projects Medicare payments to radiation oncology will rise 2% in 2027 under the rule’s changes, while payments to hematology/oncology will remain unchanged.
Payments are projected to rise 4% for radiation oncology services in freestanding centers and physician offices and fall 2% for services in hospitals and other facilities.
The projections do not include the conversion factor Medicare uses to set payments. The conversion factor falls 2.31% for most clinicians in 2027, lowering payments for all services. - The Enhancing Oncology Model — CMS Innovation Center’s payment model for oncology practices — will count as an advanced alternative payment model in 2027. Oncologists who meet the model’s participation thresholds will see a smaller conversion factor cut of 1.83%, compared with 2.31%. They will also be exempt from the Merit-based Incentive Payment System, Medicare’s main quality reporting program.
Oncologists who met the participation thresholds for an advanced alternative payment model such as the Enhancing Oncology Model in 2026 will receive a lump-sum bonus in 2028 equal to 3.1% of their 2027 Medicare payments for professional services. - CMS raised the value of 3D conformal and intensity-modulated radiation treatments by about 12% for 2027, before the conversion factor cut. The change came after early 2026 claims showed CMS had overestimated how often the most complex radiation treatments are billed. Those treatments made up about 18% of claims, compared with the 35% CMS assumed when it restructured the codes in 2026.
- A single national rate for proton therapy will replace rates set by regional Medicare contractors. In 2024, Medicare paid between $122.15 and $1,374.26 for one commonly billed proton treatment, depending on the region.
CMS set the national rates so Medicare’s total spending on proton therapy stays the same, which means centers in regions that paid more than average will see lower rates and centers in regions that paid less will see higher ones. CMS declined requests to delay national rates until 2028.
- CMS will keep two billing codes for robotic stereotactic radiosurgery, rejecting an American Medical Association committee’s recommendation to eliminate them. Collectively, the codes accounted for about 15,000 Medicare claims in 2024, according to figures in the final rule.
- Medicare will pay for several new or restructured cancer procedure codes in 2027, including irreversible electroporation of pancreatic tumors, cryoablation of bone tumors and prostate biopsies. Physicians can also bill separately for embolization procedures that use a pressure-generating catheter, which are used to treat tumors.
- Medicare will pay for AI tools that analyze tumor slides and genomic data from earlier lab tests as physician services instead of lab tests. CMS based the 2027 payment rates on what Medicare pays for the tools under the lab fee schedule in 2026. The tools on CMS’ final list cover prostate, breast, pancreatic, lung and bladder cancers.
- CMS did not create a code to pay physicians for discussing clinical trials with patients but said it may propose one in future rulemaking. The potential code would cover at least 20 minutes spent counseling patients about trial options.
- CMS will end traditional MIPS reporting after 2030, two years later than it proposed.
Starting in 2031, oncologists and hematologists who report to MIPS will have to use specialty-specific measure sets, such as the Advancing Cancer Care pathway, instead of choosing their own measures. - CMS added two measures to the Advancing Cancer Care pathway on anti-nausea treatment for patients receiving cancer drugs and removed a measure tracking whether patients’ pain levels are measured during chemotherapy or radiation.
- CMS declined to raise the threshold at which the manufacturer of Leukine, an immune-boosting drug, must pay Medicare back for unused drug left in single-dose vials. The manufacturer argued that the smaller doses used in cancer vaccine research would leave more of each vial unused.
- CMS did not raise payment for scalp cooling in 2027, despite requests to account for more nurse time and higher supply costs.
Read the full rule here.
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