In a component of the proposed 2027 Medicare physician fee schedule Texas physicians decry as particularly disturbing from a patient care standpoint, the Centers for Medicare & Medicaid Services (CMS) proposes to slash doctors' payment when they bill an office/outpatient evaluation and management (E/M) service using modifier 25 on the same day as certain global procedures.
While being touted as a measure to reduce health care costs, Texas Medical Association President Bradford W. Holland, MD, warns the proposed change could create a perverse incentive under which patients who could have been treated in one visit end up having to be treated in two visits, a move he calls “unacceptable for patient care.”
As currently proposed, Medicare would pay for the most expensive service at 100% and all other E/M visits or surgical procedures at 50%, based on TMA’s ongoing analysis of the 700-plus page document.
In a fee schedule already riddled with pay cuts, the modifier 25 change – which CMS similarly proposed and medicine successfully protested for 2019 payment – represents a “double whammy” for patients' access to care and physician practice viability, Dr. Holland warned.
As an otolaryngologist in Waco, Dr. Holland says he and his patients will see the direct impact of these cuts on many of the procedures he performs day in and day out.
Texas physicians routinely diagnose and treat patients in a single visit to avoid unnecessary care delays, and "if this modifier 25 policy is ultimately adopted, we are deeply concerned about the potential impact on patient access to timely care,” he said.
Additionally, struggling physician practices will face another layer of administrative hassles with extra billing requirements only to receive half the pay for one of their services, which Dr. Holland said amounts to "a much larger pay cut" for physicians, on top of others also proposed in the 2027 fee schedule.
As part of an ongoing series on the proposed 2027 Medicare Physician Fee Schedule, Texas Medicine Today brings you this initial analysis of the modifier 25 cut, which includes details on how to share your concerns directly with CMS on how this proposal would impact your patients and practice.
Hear more from Dr. Holland in this Facebook video.
TMT will continue to provide updates on the fee schedule as TMA combs through the document in preparation to submit comments to CMS by its Sept. 14 deadline.
Follow TMA’s Medicare Advocacy page for the latest developments.