|
Big Changes Ahead: 2027 Physician Fee Schedule Proposed Rule
On July 14, The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule impacting coding and payment for 2027. The most significant change is the conversion factor, which last year was split into two categories - one for qualifying alternative payment model participants (QPs) and another for non-qualifying QPs. Although the statute requires updating the QP rate +.75% and non-qualifying .25%, the Working Family Tax Cut (WFTC) of 2.50% expires in 2026, meaning this will be adjusted off for 2027. The net effect of this change will calculate the QP conversion factor to $33.17 (a reduction of 1.19%) and a non-QP to $32.84 (a reduction of 1.68%) for 2027.
A significant change was proposed for Modifier -25, a separately identifiable E/M service on the day of another procedure or service and Modifier -57, an E/M service that resulted in the the initial decision to perform a major surgery. CMS stated that this combination of E/M and procedures represent an overvaluing of work and is therefore a duplicative payment. They are proposing the most expensive service (either surgical or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit(s) furnished on the same day would be paid at 50%.
The complexity HCPCS code G2211 will likely transition to a modifier (MOD1) that would append to an E/M code. Rather than paying a flat rate, the modifier would increase the E/M value by 16% to maintain an equal percentage across all applicable codes. A second modifier (MOD2) would be available only for practitioners participating in a Shared Savings Program ACO or Participant Providers in a Long-term Enhanced ACO Design (LEAD) Model ACO and would increase payment of the associated E/M visit by 32%. The MOD2 modifier is optional under the LEAD Model and may be reported for any beneficiary receiving services from a participating provider - it is not limited to beneficiaries aligned with the LEAD Model. Claims submitted with the MOD2 modifier will be used in beneficiary assignment, historical benchmark spending calculations, and performance year expenditure calculations for the Shared Savings Program.
Remote physiologic monitoring (RPM) and remote therapy monitoring (RTM) will likely require a separate initiation visit in association with the onset of these services. It is also proposed to only allow payment for RPM and RTM when performed by clinical staff employed by the practice and not delivered by contractors. CMS is also set to limit these services to established patients. They are also considering bundling the RMP and RTM CPT codes and creating four new HCPCS G-Codes to describe remote monitoring services.
CMS continues to seek comments on restructuring the global payment rules. Several years of data analysis continues to show that post-operative visits are not occurring based on the current RVU allocation. They are soliciting public comments on expanding our data collection as well as other data sources we might consider to more accurately value payments for global surgical services.
Two new codes are likely to publish next year for Advanced Care Planning. These codes would define clinical staff time under direct supervision of the billing provider. The current codes 99497 and 99498 would be confined to he billing practitioner's time with the patient.
RHCs (Rural Health Clinics) and FQHCs Federally Qualified Health Centers) will likely see diabetes self-management training (DSMT) and medical nutrition therapy (MNT) move out of the all-inclusive air rate to stand-alone billing code. Similar to care management services, CMS is working to expand services to Medicare beneficiaries in rural areas and further support federal initiatives to strengthen rural healthcare.
For CY 2027, CMS is requesting stakeholder feedback on ways to better value primary care services to support its long-term goal of shifting the healthcare system from reactive treatment to a greater emphasis on prevention. Building on previous efforts within the Physician Fee Schedule and CMS Innovation Center models, CMS is specifically seeking input in three areas: reevaluating how primary care is reimbursed under the PFS, understanding how technology should be incorporated into primary care payment, and exploring prospective payment methodologies for primary care within the Medicare Shared Savings Program, with the potential for broader implementation across Original Medicare.
You can read the full CMS press release HERE.
| 
