A proposed change to how Medicare pays doctors could mean an extra trip to the office for routine care like mole checks, wart removal, or earwax cleaning. Under a rule federal officials are weighing for 2027, Medicare would pay only half as much when a patient gets a same-day evaluation and a minor procedure during a single visit, a shift physicians say could push practices to split care into two separate appointments instead of one.
The proposal comes from the Centers for Medicare & Medicaid Services, which published its draft Calendar Year 2027 Physician Fee Schedule rule, known as CMS-1848-P, on July 14, and opened a public comment period that closes September 14, according to ABC13 Houston. As the station reports, the agency is expected to make its final decision in November, with any changes taking effect January 1, 2027. Medicare, the federal program covering Americans 65 and older as well as people with disabilities, currently reimburses doctors close to full rates for both a check-up and a separate same-day procedure. Under the proposed formula, described by the Coker Group, Medicare would pay 100% of the allowed rate for only the single highest-valued service in an encounter, then cut reimbursement by 50% for any additional qualifying evaluation and management visit or minor procedure performed the same day.
Why a Routine Mole Check Could Mean Two Trips
The cut specifically targets Modifier 25, a billing code doctors attach to outpatient evaluation visits when they perform a significant, separately identifiable assessment alongside a procedure that falls under a 0-, 10-, or 90-day global surgery period, according to Cosentus, a healthcare billing firm. Same-day services that could be affected range from bloodwork and vaccines to earwax removal, toenail clipping, EKGs, urine testing, and pregnancy tests, per ABC13's reporting. Sunaina Likhari, a dermatologist in Sugar Land, told the station that parents may not be able to have procedures performed the same day next year if the rule takes effect.
Felicity Mack, a general practitioner at Balance Family Medicine and a Harris County Medical Society board member, said the proposed changes could make procedures financially unsustainable for practices, since medical offices already operate with overhead exceeding 50%. She also warned that commercial insurers often follow Medicare's lead on payment policy, meaning private plans could adopt similar cuts if the federal rule is finalized.
A Long Drive Made Longer
For patients like Vickie Jetelina, who lives in Wharton, roughly an hour and fifteen minutes from Balance Family Medicine, the change could mean more than just a scheduling headache. ABC13 notes the proposal could increase patients' transportation costs and narrow their care options if routine visits and procedures can no longer be handled in a single appointment. Mylo Johnson, a Medicare patient with a spinal cord injury who was a gunshot victim, told the station the proposed changes are frustrating and make patients feel uncared for.
A Familiar Fight for Physician Groups
This is not the first time CMS has floated a cut like this. The agency proposed a similar reduction to Modifier 25 payments back in July 2018 for the 2019 fee schedule but withdrew it after widespread physician pushback, giving the American Medical Association's CPT Editorial Panel time to reform evaluation and management coding guidelines, according to the American Medical Association. AMA President Dr. Willie Underwood III said this year that CMS based its new 50% cut on an unsubstantiated assumption of “likely” resource duplication without offering empirical data to justify the reduction.
More than 140 national and state medical organizations, including the AMA, the American College of Physicians, and the Texas Medical Association, submitted joint comments urging CMS to abandon the cut entirely, according to the Michigan State Medical Society. Texas Medical Association President Dr. Bradford W. Holland, an otolaryngologist practicing in Waco, said the policy creates a “perverse incentive” that would force physicians to split care into two separate appointments, threatening timely patient care across Texas.
The Numbers Behind the Pushback
A financial impact analysis released in August estimated the Modifier 25 cuts would reduce total Relative Value Units, the standardized units CMS uses to calculate reimbursement, by roughly 9% for dermatology and otolaryngology practices and 7% for orthopedic surgery practices, per Cosentus. CMS has also solicited feedback on alternatives, including a smaller 25% reduction or extending same-day payment cuts to inpatient hospital visits, the Coker Group reports.
It would not be the first time a major insurer tried something similar. In March 2023, commercial insurer Cigna attempted to require additional documentation and reduce payments for Modifier 25 claims, but paused the policy after intense lobbying from the Harris County Medical Society, the Texas Medical Association, and the AMA. With the federal comment period closing September 14 and a final decision expected in November, physician groups are again pushing for CMS to scrap the cut altogether, much as they did in 2019.
