2025 vs 2026 Medicare Reimbursement for Urology: What's Changing and What Practices Should Watch

Minerva Reimbursement Briefing

A code-by-code comparison built directly from raw CMS rate files — PFS, OPPS, and ASC — covering the conversion factor change, the efficiency adjustment, the prostate biopsy code overhaul, the new Aquablation Category I code (52597), and what urologists and practice managers should prepare for in 2026.

The headline: a site-of-service paradox

The Medicare 2026 final rules created an unusual split for urology. On the surface, the Physician Fee Schedule (PFS) conversion factor went up — from $32.3465 in 2025 to $33.4009 in 2026 (a 3.26% increase for non-QPP participants). Practice managers reading the fact sheet might expect higher payments.

The reality is the opposite. Because CMS layered two structural changes on top of the conversion factor — a 2.5% efficiency adjustment applied to work RVUs on most non-time-based codes, plus a practice expense (PE) methodology revision that cut facility PE for work-RVU-allocated codes to half of non-facility PE — almost every major urology procedure paid in a hospital or ASC setting lost ground under the PFS.

At the same time, the OPPS and ASC payment systems received a +2.6% market basket update (3.3% market basket minus a 0.7-percentage-point productivity adjustment). The result is that the facility gets paid more in 2026 while the physician working in that same facility gets paid less — and the patient never sees the difference.

What changed in the 2026 PFS final rule

• Conversion factor (non-QPP): $32.3465 → $33.4009 (+3.26%). A statutory 2.5% one-time increase plus the standard budget-neutrality adjustment got us there.
• Efficiency adjustment (−2.5%): CMS finalized a −2.5% adjustment to work RVUs for non-time-based services, citing improvements in physician efficiency over time. This applies broadly across the schedule and will be revisited every three years.
• PE methodology revision: For codes whose practice expense is allocated by work RVUs, the facility PE RVU is now capped at one-half of the non-facility PE RVU. This is the single biggest driver of the PFS facility cuts on procedure codes.
• Indirect PE recalibration: CMS updated specialty-level practice cost data using the 2017–2021 American Hospital Association Survey of Hospitals.

Code-by-code: 2025 vs 2026 Medicare payment

Every figure below was computed directly from raw CMS rate files (PFS RVU files, OPPS Addendum B, ASC Addendum AA), using CF 2025 = $32.3465 and CF 2026 = $33.4009. PFS uses Total Facility RVU × CF. OPPS uses the published payment rate per APC. ASC uses Addendum AA payment rate. Carrier-priced and NA-indicator cells are shown as "—".

Prostate procedures

Bladder, cystoscopy, and tumor resection

Stones and ureter

New 2026 codes urologists need to know NEW

Aquablation gets a Category I code

The waterjet ablation procedure formerly billed under Category III 0421T received a permanent Category I code in 2026: 52597, with CMS short descriptor "Trurl rbtc wtrjt rescj prst8" (transurethral robotic waterjet resection of prostate).

• PFS facility: $548.44
• OPPS: $9,671.50 (APC 5376, SI = J1, comprehensive APC)
• ASC: $6,949.81

Prostate biopsy code family — complete overhaul

The legacy biopsy code 55700 is deleted for 2026, replaced by a nine-code family 55707–55715 that bundles imaging guidance directly into the biopsy code. This is the most significant urology code change in years.

Codes deleted for 2026 DELETED

• 55700 — Biopsy of prostate (replaced by 55707–55714) (2025 PFS facility was $124.86)
• 52647 — Laser coagulation of prostate (legacy; functionally replaced by 52648/52649) (2025 PFS facility was $634.64)
• 0421T — Waterjet ablation of prostate (Cat III; replaced by Cat I 52597) (2025 PFS facility was —)

Hospital outpatient and ASC supply pack updates

CMS also revised three urology-relevant supply packs in OPPS/ASC, with values phasing in over four years to mitigate disruption. The 2026 values for the most common packs:

• SA058 (cystoscopy disposable pack): $94.68 in 2025 → $75.67 in 2026, phasing to $37.63 by 2029 (~−60% over 4 years)
• SA042 (urology procedure pack): $22.40 → $25.36, phasing up to $31.29 by 2029
• SA051 (minor urology pack): $20.16 → $14.38, phasing to $2.81 by 2029
• SD089 (new packaged drug supply): $27.42 in 2026, phasing up to $41.15

Supply pack values are embedded inside packaged APC rates, so they affect comprehensive APC payments rather than appearing as separate line items.

Practice manager checklist: 30 / 60 / 90 days

By January 1, 2026 (Day 0)

• Load 2026 CMS fee schedules into your PM/EHR; verify 2026 conversion factor is $33.4009 (non-QPP) and $33.5875 (QPP).
• Update payer fee schedules and contract loaders — particularly Medicare Advantage plans that mirror CMS with a multiplier.
• Inactivate 55700, 52647, and 0421T in your procedure master file.
• Add 52597, 55707–55715 with full work-RVU and APC mappings.
• Brief surgeons and biopsy coordinators on the new prostate biopsy code structure — image-guidance bundling is the highest-risk coding change of the year.

First 30 days

• Audit denials and rejection codes daily; the new biopsy codes will hit edits at most commercial payers in January.
• Confirm prior-authorization templates were updated for 52597 (Aquablation) — most commercial payers will require an updated medical policy reference.
• Pull a sample of 50 cystoscopy + biopsy + ureteroscopy claims and compare actual remittance to your model. PFS facility cuts hit the professional component of these.

60–90 days

• Model 2026 vs 2025 net Medicare revenue at the procedure-line level. Pay special attention to high-volume TURP, PVP, and HoLEP cases.
• Revisit your site-of-service strategy: in many markets the PFS-down/HOPD-up paradox means a hospital-employed model now collects more total Medicare dollars than an independent professional model on the same procedure. Owned ASCs are the strongest economic position in 2026.
• Open commercial payer negotiations with the data. Multi-year contracts that mirror Medicare PFS will compound the cuts; you may have leverage to break that linkage.
• Audit your transperineal vs transrectal biopsy mix. The new code family pays more for transperineal and MR-fusion; if your infection rates also favor transperineal, the clinical and financial case lines up.

Bottom line

2026 is not a flat year for urology. Headline statements like "the conversion factor went up 3.26%" obscure a structural redistribution: facility-based professional fees are down meaningfully, hospital and ASC facility payments are up, and the prostate biopsy and Aquablation code changes will require workflow updates at virtually every urology practice in the country. Practices that prepare in November and December — and that model their own data rather than relying on summaries — will run a much cleaner Q1 than those that wait.

Methodology

All payment values in this article were computed by Minerva Health Solutions directly from CMS-published raw data files. No values were estimated, recalled, or sourced from third parties. Specifically:

• PFS payment = (Work RVU + PE RVU + MP RVU) × Conversion Factor. CF 2025 = $32.3465. CF 2026 (non-QPP) = $33.4009. NA indicators, status codes (X, N, I, R, C), and global periods were honored per CMS payment rules.
• OPPS payment = Addendum B published payment rate for each HCPCS code's APC.
• ASC payment = Addendum AA published payment rate.
• Source files used: PPRRVU25_JAN.csv (released 12/23/2024), PPRRVU2026_Jan_nonQPP.csv, 508 Version of January 2025 Web Addendum B (12/31/2024), 2026 January Web Addendum B (12/29/2025), 508 Version Jan 2025 ASC Addendum AA (01/21/2025), January 2026 ASC Addendum AA (02/05/2026).

References

All hyperlinks below were verified against CMS, AHA, and AUA primary sources. Where third-party commentary is cited, it is used for contextual policy interpretation only — never for payment values.

Primary CMS sources (raw data files)

1. Centers for Medicare & Medicaid Services. Physician Fee Schedule — PFS Relative Value Files (CY 2025 & CY 2026). https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files
2. Centers for Medicare & Medicaid Services. Hospital Outpatient PPS — Addendum A and Addendum B Updates (January 2025 & January 2026). https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/addendum-a-addendum-b-updates
3. Centers for Medicare & Medicaid Services. Ambulatory Surgical Center (ASC) Payment — Addenda AA, BB, DD1, DD2, EE (January 2025 & January 2026). https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-regulations-and-notices

CMS rules, fact sheets, and federal register notices

4. CMS. Calendar Year 2025 Medicare Physician Fee Schedule Final Rule — Fact Sheet. November 1, 2024. https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-medicare-physician-fee-schedule-final-rule
5. CMS. Calendar Year 2026 Medicare Physician Fee Schedule Final Rule — Fact Sheet. October 31, 2025. https://www.cms.gov/newsroom/fact-sheets/calendar-year-2026-medicare-physician-fee-schedule-final-rule
6. CMS. CY 2026 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1834-FC) — Fact Sheet. November 2025. https://www.cms.gov/newsroom/fact-sheets/calendar-year-2026-hospital-outpatient-prospective-payment-system-opps-ambulatory-surgical-center
7. CMS. CY 2026 OPPS/ASC Final Rule — Federal Register Display Copy. https://www.cms.gov/files/document/cms-1834-fc-display-version.pdf
8. CMS. MLN Matters — Annual Update to the Medicare Physician Fee Schedule Database (MPFSDB). https://www.cms.gov/medicare/payment/fee-schedules/physician

Industry analysis and coding guidance

9. American Hospital Association. CMS issues CY 2026 physician fee schedule final rule. AHA News, October 31, 2025. https://www.aha.org/news/headline/2025-10-31-cms-issues-cy-2026-physician-fee-schedule-final-rule
10. American Urological Association. Coding Tips and Tricks: Medicare Proposed Rule for 2026 — Important Take-Home Points for Urologists and Urology Practices. AUA News, September 2025. https://auanews.net/issues/articles/2025/september-2025/coding-tips-and-tricks-medicare-proposed-rule-for-2026-important-take-home-points-for-urologists-and-urology-practices
11. MedCare MSO. Urology CPT Codes 2026: Aquablation (52597), Prostate Biopsy Overhaul (55707–55715), and Deleted Codes. https://medcaremso.com/blog/urology-cpt-codes-2026/
12. American Medical Association. CPT 2026 Code Set — Summary of Additions, Deletions, and Revisions. https://www.ama-assn.org/practice-management/cpt

Methodology references

13. CMS. Practice Expense Methodology. Medicare Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician/pe
14. CMS. PFS Conversion Factor — Calculation and History. https://www.cms.gov/medicare/payment/fee-schedules/physician
15. MedPAC. Report to the Congress: Medicare Payment Policy — Physician Services Chapter. March 2025. https://www.medpac.gov/document/march-2025-report-to-the-congress-medicare-payment-policy/