Medicare Wants to Halve Some Same-Day Office Visits. Family Physicians Say It Was 'a Bad Idea' the Last Time Too.

Legislation by DPC Insider — Policy Desk
#medicare#physician fee schedule#modifier 25#cms#aafp#fee-for-service#coding
Sources: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule (Federal Register, July 16, 2026) · Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Rule (CMS fact sheet) · AAFP comment letter to CMS on the CY 2027 Physician Fee Schedule proposed rule (September 11, 2026) · AAFP Summary of the CY 2027 Medicare Physician Fee Schedule Proposed Rule · Estimated payment impact of the CY 2027 Medicare Physician Fee Schedule proposed modifier 25 policy on same-day dermatology services (Milliman) · Dude, Where's My Modifier? (DPC News)

Medicare has proposed cutting payment when the same doctor does an office visit and a procedure with a 0-, 10- or 90-day global period on the same day. The more expensive service would be paid in full and the other at half. The policy sits in the CY 2027 Physician Fee Schedule proposed rule, and CMS has floated it before. In the CY 2019 fee schedule it proposed a narrower cut, limited to 0-day global procedures, and didn’t finalize it.

The American Academy of Family Physicians remembers. Its September 11 comment letter put it bluntly: “It was a bad idea then, and it has gotten no better in the intervening years.”

The comment window closed September 14. The AAFP’s own summary of the proposed rule says the final rule will be released around November 1 and take effect January 1, 2027.

What CMS actually proposed

Modifier 25 is the code a physician appends when an office visit is “significant and separately identifiable” from a procedure done the same day. A patient comes in for one problem, the doctor finds a second, and treats it on the spot. Today the visit is paid as its own service when it clears that bar.

Under the proposal, when a separately identifiable office visit happens on the same day as a procedure with a 0-, 10- or 90-day global period, CMS would pay “the most expensive service” at 100% and “all other surgical procedure(s) or E/M visit(s)” at 50%. It applies to the same physician or a physician in the same group practice.

CMS walked through its own example in the rule. A patient gets a level 2 established-patient visit, CPT 99212, then has two skin lesions shaved. Using 2026 values, the visit is worth 1.78 total RVUs. Under the proposal it drops to 0.89.

The agency also asked two open questions. Would a 25% reduction be more appropriate than 50%? And should the cut extend beyond office visits to inpatient E/M?

Why CMS says it’s overpaying

The argument is about overlap. CMS says there are efficiencies when the same physician provides a visit and a global procedure for one patient on one day, and that Medicare is “likely duplicating payment” under the current method.

That position has support. When CMS floated the CY 2019 version, according to the rule’s own history, MedPAC backed the earlier proposal, citing pre- and post-service efficiencies the payment system doesn’t capture.

CMS expects the heaviest losses in otolaryngology, dermatology and podiatry. “Most other specialties receive a small increase due to the redistribution of those RVUs,” the rule says. For family physicians, the AAFP’s analysis of the proposed rule, republished by the Louisiana Academy of Family Physicians, says they “are projected to see a positive 1% impact on total allowed charges in 2027.”

Dermatology’s estimate is far worse. A Milliman analysis commissioned by the American Academy of Dermatology Association put the total reduction at $969 million in 2024 terms. That’s about 0.6% of Part B physician and supplier allowed charges. Dermatology alone would absorb $291 million, roughly 6.1% of its Part B allowed amount.

Why family physicians object anyway

Across the rule as a whole, family medicine comes out ahead on paper. The AAFP opposes the policy regardless, and its reasons are about behavior more than dollars.

The first is scheduling. The letter says the policy “encourages medical practices to turn patients away for same-day procedures and have patients return another day.” CMS doesn’t deny the risk. It says it does not find it appropriate to schedule services “to maximize payment” and points to claims edits, comparative billing reports and medical review as ways to catch it.

The AAFP calls that inadequate. A patient with limited mobility who has to come back for a second trip is harmed whether or not CMS later flags the pattern.

The second is referral. Practices that can’t absorb the cut may send the procedure to a higher-cost subspecialist, the letter argues. The third is double-counting. The AMA’s RUC already adjusts for same-day overlap when it values these codes, so CMS would be applying a second reduction on top.

The letter also flags osteopathic manipulative treatment. OMT is billed as a procedure but is often part of a routine primary care visit, so DO-led practices would take the cut on ordinary encounters.

The AAFP’s fallback ask is specific. If CMS moves forward, it “should exempt primary care physicians and other clinicians predominantly furnishing primary care services.”

It also points to private payers. The AAFP says Anthem announced the same policy, then halted it. DPC News makes the same point from the other direction: “insurance companies follow what Medicare does.” If that holds, a Medicare rule on modifier 25 can reach practices that see few Medicare patients.

The membership practice’s version of the same visit

The DPC community noticed. On October 9, DPC News put the contrast plainly: “Direct Primary Care doctors no longer code. There are no modifiers.”

That holds for this rule in a narrow way. In a DPC practice that covers office procedures in the monthly fee, the visit and the joint injection or lesion removal aren’t separate line items. There’s no second service for a payer to reduce. And there’s no financial reason to book the procedure for next Tuesday.

The scheduling incentive the AAFP describes, and that CMS says it may monitor, only exists where each service on a given day has its own price.

What to watch

The final rule is expected around November 1. Four details in it will decide how much this matters to primary care.

  • The percentage. CMS asked whether 25% would be more appropriate than 50%.
  • A primary care exemption. The AAFP asked for one by name. Watch whether CMS carves out clinicians who mainly furnish primary care.
  • Scope. Inpatient E/M is on the table as an extension.
  • Enforcement on scheduling. CMS asked whether to revise conditions of payment to stop practices from splitting visits across days.

If CMS finalizes it as written, the change takes effect January 1, 2027. If it drops it again, as it did for 2019, expect the idea to come back. CMS said in this rule that it still believes, as it did in the CY 2019 final rule, that it is “likely duplicating payment.”