MGMA presses CMS to drop 50 percent same-day payment cut

Medicare's 2027 pay proposal would pay a practice in full for one service and 50 percent for the other when an office visit and a procedure happen on the same day. MGMA spent the closing hours of the Sept. 14 comment window trying to kill it.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, said the same-day reduction is near the top of the association's 32-page comment letter on the calendar year 2027 Medicare Physician Fee Schedule proposed rule, and it is one of the few big-ticket items CMS could fix on its own. "This is something that concerns us a great deal," he said.

Under the proposed rule, when a separately identifiable evaluation and management visit billed with modifier 25 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 at 100 percent. Every other service that day would be paid at 50 percent. CMS has said it believes the current methodology likely duplicates payment when the same physician provides an E/M service alongside a procedure with a global period.

Gilberg's example was a dermatology visit where the physician spots something during the exam and handles it on the spot. "We're not talking about an excessive amount of money, but it's certainly convenient for the patient and good care to get that done immediately," he said. "With this proposal, you could be in situations where patients are going to have to be asked to come back the next day in order to get these secondary procedures."

MGMA's letter argues the cut is not supported by evidence. CMS has pointed to its multiple procedure payment reduction policies as precedent, which the association said ignores that those policies were built to capture efficiencies among multiple services of the same or similar type. Where CMS believes specific codes carry overlapping work or practice expense, the letter said, the agency already has the RUC and the misvalued code initiative to address it, rather than an across-the-board reduction.

The reach is the problem. Modifier 25 marks significant, separately identifiable work that goes beyond the global procedure, and MGMA listed dermatology, otolaryngology, family medicine, podiatry, rheumatology, ophthalmology and orthopedic surgery among the specialties that use it to deliver same-day care. The association also warned of knock-on effects if commercial insurers adopt the same reduction.

MGMA said numerous procedures already run at or near break-even, and that members from mid-size rheumatology groups to OB/GYN practices have described potential losses of hundreds of thousands of dollars from this cut alone. One rural practice framed the tradeoff to MGMA as a choice between providing care and making payroll. The association's concern is that practices respond by scheduling procedures on a separate day, which is worse for the patient and the schedule alike.

CMS proposed a similar policy in 2019 and dropped it after public feedback. MGMA said the agency has not cited new evidence for reviving it. The association joined the Same Day Care Coalition in August and filed a separate letter urging withdrawal, and Gilberg said the coalition has taken the issue to the White House and Capitol Hill.

What worries Gilberg is how little has moved between proposed and final rules lately. "A lot of the proposals get pretty much finalized in their totality," he said.

The final rule is expected on or about Nov. 1, roughly two months before the policy would take effect. Practices weighing the exposure can start with the parts of the proposal that touch their own code mix.

"You're not going to hear anything in terms of whether or not some of these things, like the 25 modifier, the same-day cut, is finalized until the 11th hour," Gilberg said. "Be very, very much on guard to make sure you understand what's in the final fee schedule."