In the proposed 2027 Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) would cut payment when certain procedures are performed during the same visit as a separately identifiable evaluation and management (E/M) service. In a new series, ACS Health Policy Alert, ACS surgeon coding experts are examining this topic in an article: A Proposed Medicare Payment Cut You Should Know - Modifier 25 & Overlapping Services, Part 1.
The Issue
Today, physicians can be paid for both services when they perform a procedure and a significant, separately identifiable E/M service during the same visit. Modifier 25 is used to indicate that the E/M work was distinct from the procedure.
Under the proposed policy, Medicare would reduce payment for the lower-valued service by 50%.
Why It Matters
When a surgeon provides two distinct services during one visit, Medicare should not automatically treat that work as less valuable. For surgeons, the proposal could mean lower Medicare payment for distinct services provided during the same patient visit.
For patients, the proposal raises concerns about additional appointments, travel, time away from work or family, and potential delays in care.
What the ACS Found
Christopher P. Childers, MD, PhD, and Don J. Selzer, MD, MS, FACS, members of the ACS General Surgery Coding and Reimbursement Committee, and Thomas C. Tsai, MD, MPH, FACS, ACS Medical Director, Health Policy Research, analyzed Medicare claims to understand how the proposal would work in practice.
Based on current Medicare use patterns, 1,458 procedures would be affected. In one example, a patient sees a colorectal surgeon for rectal bleeding. The surgeon evaluates the patient and performs an anoscopy during the same visit. Today, the total work relative value units (RVUs) for the services are 3.14. Under the new proposal, the total work RVUs are reduced to 2.87, an 8.6% lower total valuation.
The analysis found that the proposal would affect procedures across a broad range of office-based specialties, including general surgery, colorectal surgery, plastic surgery, orthopaedics, head and neck surgery, and urology.
What the ACS Is Doing
ACS researchers examined Medicare data to understand who would be affected, quantify the potential consequences, and identify key concerns raised by the proposed policy.
That evidence helps the ACS make the case for Medicare payment policies that appropriately value surgical care and do not create unintended consequences for surgeons or their patients.
What's Next
The researchers also asked: If CMS believes payment should be reduced when physician services overlap, is that principle being applied consistently across Medicare? Additional insights will be shared in an upcoming issue of the ACS Brief.
Get Involved
This proposal is one of several Medicare payment policies the ACS is working to address. You can help. Use SurgeonsVoice to ask your members of Congress to cosponsor the Efficiency Adjustment Delay Act and stop harmful cuts to work RVUs.
