If you or a loved one relies on Medicare, a proposed change buried inside this year’s Medicare Physician Fee Schedule could quietly reshape the way you receive care — turning what is currently a single, efficient visit into two separate appointments. Here’s what the proposal is, why it matters, and what you can do about it before the comment window closes.
What Is Being Proposed?
The Centers for Medicare & Medicaid Services (CMS) has released its Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule (CMS-1848-P). Tucked inside is a proposal to reduce payment for evaluation and management (E/M) office visits when a minor procedure is performed on the same day.
In plain language: if your doctor examines you, diagnoses a problem, and treats it in the same visit — for example, by performing a biopsy, joint injection, cerumen (earwax) removal, or lesion removal — the practice would be paid significantly less than they are today for that combined care.
A Quick Explainer: What Is “Modifier 25”?
Modifier 25 is a billing code that has existed for decades. It is added to a claim when a physician provides a “significant, separately identifiable” evaluation and management service on the same day as a procedure.
In other words, Modifier 25 is how the system recognizes that:
- The thinking work (history, exam, differential diagnosis, decision-making, counseling), and
- The procedural work (the biopsy, injection, or removal itself)
…are two distinct services that both took time, skill, and resources — and both should be reimbursed.
Current rules already require strict documentation showing that the office visit was separate and significant from the procedure. Claims can be — and regularly are — audited, denied, or recouped when documentation does not support the modifier.
Why the Proposed Rule Is Concerning
When Medicare payment drops sharply for same-day care, practices face a difficult financial choice. In many cases, the predictable response is to schedule the evaluation on one day and the procedure on a later day, simply to keep the practice financially viable.
For patients, that means:
- Two copays instead of one
- Two trips to the doctor’s office
- Two days off work for the family member or caregiver who drives them
- Additional transportation, parking, and waiting time
- Days — sometimes weeks — of waiting between finding a concern and treating it
For Medicare beneficiaries who no longer drive, live in rural areas, depend on caregivers, or manage multiple chronic conditions, “just come back next week” is not a neutral request. For some, it means the follow-up simply doesn’t happen.
Delay Is Not Clinically Neutral
Same-day care is not just convenient — it is often clinically important. Common examples include:
- A suspicious mole or skin lesion biopsied during a routine visit, catching a melanoma early
- A joint injection to relieve arthritis pain the same day a patient describes new symptoms
- Incision and drainage of an abscess before an infection worsens
- An endometrial biopsy performed during the visit at which an abnormal finding is discussed
- Cerumen removal that restores hearing during a wellness visit
Asking patients to return on a separate date for these procedures introduces delay, additional cost, and additional anxiety. For time-sensitive findings, weeks of waiting can meaningfully affect the diagnosis, treatment, and outcome.
Why This Affects More Than Just Medicare Patients
Medicare is the largest single payer in the United States, and commercial insurers routinely follow Medicare’s lead on payment policy. When CMS reduces payment for a specific type of care, private plans frequently adopt similar rules within one to two years.
That means a rule finalized for Medicare beneficiaries this year could shape how working-age adults, families, and children experience care in the near future.
The Existing System Already Prevents Misuse
Concerns about the appropriate use of Modifier 25 are legitimate, and CMS already has tools to address them:
- Strict documentation requirements
- Medicare Administrative Contractor (MAC) audits
- Post-payment review and recoupment
- Targeted review of specific overvalued code pairs
These tools address bad billing on a case-by-case basis, grounded in the medical record. A blanket, across-the-board payment cut does not distinguish between a practice that is misusing the modifier and a practice using it exactly as CMS intended. It simply reduces payment for legitimate, medically necessary same-day care — and shifts the downstream cost onto patients.
The Public Comment Period: Your Voice Matters
CMS is legally required to review and respond to public comments on proposed rules before finalizing them. Individual patient and clinician voices genuinely factor into the record — but only if they are submitted.
Deadline: Comments must be received by September 14, 2026 to be assured consideration.
How You Can Take Action Today
Contact Your Representatives in Congress
Ask them to urge CMS to withdraw the proposed Modifier 25 payment reduction. Click here to contact your representatives
Submit a Public Comment to CMS
Your comment becomes part of the official record. Deadline: September 14, 2026. Leave a comment on Medicare’s website
Not Sure What to Write?
Download our ready-made comment template and personalize it in just a few minutes. Download the Word document comment template
Share This Article
Send it to family, friends, and neighbors — especially those on Medicare or caring for someone who is. Post it on social media. Print it out for community bulletin boards and waiting rooms. Every voice adds weight.
The Bottom Line
Same-day care saves patients time, money, caregiver support, and, in some cases, better health outcomes. The current framework — Modifier 25 combined with documentation requirements and targeted audits — already gives CMS the tools it needs to prevent misuse without penalizing the millions of appropriate, medically necessary same-day visits that happen every year.
Please take a few minutes today — before September 14, 2026 — to submit a comment and contact your representatives. This is a policy that will quietly touch nearly every patient who walks into a doctor’s office, and it deserves a loud, clear response from the people it will affect most.
