Fix the codes, not the payment: Physician groups counter CMS on same-day E/M

Nearly 150 medical organizations have told CMS that its proposed 50 percent payment cut for office visits billed on the same day as a procedure would correct a problem the agency has not shown exists. In place of the cut, they are handing CMS a narrower route: fix the individual codes where overlap can actually be demonstrated.

The request came in a sign-on letter dated Aug. 27 and addressed to CMS Administrator Mehmet Oz, MD. The American Medical Association led it, joined by more than 100 national organizations including the Medical Group Management Association, the American Academy of Family Physicians, the American College of Physicians and the American College of Surgeons, plus nearly 50 state and District of Columbia medical societies.

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 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 service that day would be paid at 50 percent.

Physicians Practice reported last week on the AMA's own case against the proposal. The sign-on letter carries that argument to CMS with a specific alternative attached.

The problem: an assumption doing the work of evidence

The central complaint is evidentiary. CMS describes the overlap it wants to remove as "likely" and says it continues to believe efficiencies exist. A reduction applied across thousands of codes and every affected specialty should rest on demonstrated duplication in identified services, the groups wrote, not on an assumption. They said CMS has not quantified the overlap, identified which resources it believes are duplicated or shown that current payment systematically overstates the work and practice expense required to furnish these services.

They also want CMS to account for 2019. The agency floated a narrower version of this policy in the CY 2019 proposed rule and declined to finalize it after reviewing comments. The 2027 version reaches further, covering 10- and 90-day global procedures and reducing every same-day service other than the highest valued one. An agency reviving and expanding a policy it previously set aside, the letter argues, should at least explain what changed.

The overlap is already stripped out once

The letter's strongest technical point is that Medicare's valuation machinery already does this job. Physician work survey instructions used by the AMA/Specialty Society Relative Value Scale Update Committee, known as the RUC, expressly exclude work associated with a distinct E/M service reported with modifier 25. The misvalued code initiative has identified and revalued codes commonly furnished with a same-day visit. CMS reviews the RUC's recommendations each year and adjusts values itself where it believes overlap has not been fully addressed. Because those reductions also lower the inputs used to allocate indirect practice expense, the groups wrote, the adjustment shows up across every component of a procedure's value. A further across-the-board cut takes a second reduction for overlap the valuation process has already removed.

The 50 percent figure draws its own objection. When CMS reduces payment for overlap elsewhere, the letter notes, it targets the specific component where the efficiency occurs, such as the technical component under the longstanding multiple procedure payment reductions for diagnostic cardiovascular and ophthalmology services. This proposal applies 50 percent to the entire value of the lower-valued service, taking physician work, practice expense and professional liability alike, including components in which CMS has identified no overlap at all.

For office-based practices, the math can go negative. Using CPT code 11300, the example CMS cites in the proposed rule, the letter puts the reduced payment at roughly $45 against about $60 in clinical staff, supply and equipment cost, before any physician work. Practices in facility settings can offset the reduction with facility revenue. Independent offices carrying those costs themselves cannot.

The fix the groups are asking for

The letter makes three requests. Do not finalize the 50 percent reduction. Do not extend it to procedures furnished on the same date as inpatient or other E/M services. And address any genuine overlap on a code-specific basis through the misvalued code and RUC valuation processes, working with physician organizations where CMS believes a particular code does not fully account for it.

The groups also asked CMS to answer three questions in the final rule: the specific evidence that separately identifiable same-day E/M services systematically contain duplicative resources and the basis for setting the reduction at 50 percent, the analysis CMS conducted on the policy's effect on independent practices and on beneficiary access in rural and underserved communities, and what evidence or circumstances have changed since 2019.

What a practice can add before Sept. 14

The societies will file the policy argument. What they cannot file is a single practice's number, and practice-level figures are the scarce commodity in a rulemaking record. Physicians Practice has published a free handbook on the proposed same-day cut that walks through the claims pull, the math on a practice's top same-day code pairs and a self-audit of modifier 25 documentation.

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. Anders Gilberg, senior vice president of government affairs at MGMA, told Physicians Practice in July that the 2027 rule still robs Peter to pay Paul.

Comments on CMS-1848-P are due Sept. 14. The final rule is expected in November.