AMA urges CMS to withdraw 50 percent same-day E/M cut

The American Medical Association is asking CMS to withdraw a proposal that would cut Medicare payment by 50 percent for an office visit billed on the same day as a procedure, arguing the agency has not produced the evidence to justify a reduction that large.

Willie Underwood III, MD, MSc, MPH, president of the AMA, made the case in a leadership viewpoint published Aug. 20. Independent practices are essential to patients in communities nationwide, he wrote, and the proposal could put the viability of some of them at risk. Private practice physicians, he added, already are under tremendous pressure trying to keep their practices open.

The provision sits in the CY 2027 Medicare Physician Fee Schedule proposed rule, released July 14. According to the CMS fact sheet, when a separately identifiable office or outpatient evaluation and management visit is furnished by the same physician, or by a physician in the same practice, on the same day as a procedure carrying a 0-, 10- or 90-day global period, the most expensive service would be paid in full and every other procedure or visit that day would be paid at 50 percent.

Modifier 25 does not disappear under the proposal, and the standard for appending it does not change. What changes is what the lesser paid service collects. In most same-day encounters that is the office visit rather than the procedure, so a practice modeling a cut to the procedure line is modeling the wrong number.

The AMA says Medicare already has a process for this

Modifier 25 already requires the visit to be significant and separately identifiable from the procedure, and code values were adjusted for overlapping work during valuation through the AMA/Specialty Society Relative Value Scale Update Committee. That argument runs through the association's summary of the proposed rule: strip the overlap out again at the claim line and Medicare removes it twice. If specific services still contain duplicative resources, Underwood wrote, those services should be identified and reviewed individually rather than swept into a blanket reduction.

The AMA also wants CMS to explain the timing. The agency floated a narrower version of the policy in the CY 2019 proposed rule and chose not to finalize it after reviewing comments from physicians. The 2027 version reaches more procedures, and the association argues the expansion needs supporting evidence the rule does not supply.

Where the cut lands

For office-based practices carrying the cost of clinical staff, supplies and equipment, Underwood wrote, CMS's own example shows the reduction could leave payment below the direct costs of furnishing the service, before any accounting for the physician's work. CMS expects the largest negative effects in otolaryngology, dermatology and podiatry. Because the fee schedule is budget neutral, specialties that rarely pair procedures with visits would see a small increase as the dollars move.

The cut would also land on top of a lower conversion factor. CMS has proposed $32.8409 for clinicians who are not qualifying alternative payment model participants, down 1.68 percent, and $33.1693 for those who are, down 1.19 percent, as the temporary 2.5 percent increase Congress provided for 2026 expires.

Run your own number before the comment window closes

Practices with heavy same-day volume have a few weeks to put a dollar figure on the exposure and get it into the record. Physicians Practice has published a handbook on the proposed same-day cut that walks through the claims pull, the math on a practice's top code pairs and a self-audit of modifier 25 documentation.

Specialty societies will file the policy argument. What they cannot file is your figure, and practice-level numbers are the scarce commodity in a rulemaking record. The free handbook lays out a six-step claims pull, a worksheet for a practice's top five same-day code pairs, a 10-question self-audit for chart review, a quick reference separating modifier 25 from 57, 59, 24 and 79, and a chapter on writing a comment CMS can use. The math is simple once the claims data is in hand: the higher allowed amount plus half the lower one, run against the proposed 2027 conversion factor rather than current-year rates.

Comments on the proposed rule are due Sept. 14. The final rule is expected in November.