Comment on CMS-2026-2377-0001

**Re: CMS-1848-P — CY 2027 Medicare Physician Fee Schedule Proposed Rule** To the Centers for Medicare & Medicaid Services: I am a fellowship-trained Mohs surgeon and dermatologist who owns and operates independent dermatology practices in Northern Virginia. Approximately half of our patients are Medicare beneficiaries, and our practices provide office-based diagnosis, treatment, pathology, Mohs surgery, and reconstruction for patients with skin cancer. I support efforts to strengthen primary care. However, primary care should not be strengthened by weakening access to medically necessary specialty and surgical care. I am particularly concerned about the proposed reduction in payment when a separately identifiable office E/M service and a procedure with a global period are provided on the same day. Under the proposal, the highest-valued service would be paid at 100%, while the additional E/M or procedure would be paid at only 50%. In dermatology, evaluation and treatment commonly and appropriately occur during the same encounter. A patient may present for a comprehensive skin examination and be found to have a suspicious lesion requiring biopsy, multiple actinic keratoses requiring treatment, or an unrelated inflammatory condition requiring separate evaluation and management. These are distinct, medically necessary services—not duplicative work. Reducing payment for these services would create several harmful incentives: * Physicians may be pressured to bring patients back on another day for a procedure that could safely and efficiently be performed during the initial visit. * Medicare beneficiaries would face additional travel, time away from caregivers, transportation challenges, and cost-sharing. * Diagnosis and treatment of potentially malignant lesions could be delayed. * Total Medicare spending could increase because two separate encounters may replace one efficient visit. * Independent office-based practices may become less financially sustainable, shifting more care into higher-cost hospital settings. Mohs surgery is also not a low-overhead procedure. An independent Mohs practice must support a CLIA-certified laboratory, histotechnologists, trained surgical staff, procedure rooms, specialized equipment, pathology supplies, sterile instruments, regulatory compliance, and the capacity to perform same-day reconstruction. These expenses continue to increase even as Medicare physician payments fail to keep pace with inflation. Office-based Mohs surgery allows patients to receive tumor removal, microscopic margin evaluation, and reconstruction in one setting and often on one day. This model is efficient, patient-centered, and generally less costly than moving equivalent care into a hospital outpatient department. I respectfully request that CMS: 1. Withdraw the proposed 50% payment reduction for separately identifiable same-day E/M and procedural services. 2. Preserve appropriate payment when modifier 25 documentation demonstrates a significant, separately identifiable E/M service. 3. Conduct a dermatology- and Mohs-specific analysis of the effects on patient access before implementing changes to procedural reimbursement. 4. Recognize the actual clinical staffing, laboratory, equipment, and regulatory costs of office-based Mohs surgery when calculating practice-expense values. 5. Avoid policies that encourage physicians to separate clinically appropriate same-day evaluation and treatment into multiple visits. 6. Establish a stable physician payment system that reflects inflation and the real cost of maintaining an independent medical practice. My practice is committed to appropriate coding, complete documentation, responsible use of Medicare resources, and high-quality patient care. Nevertheless, continued reductions to office-based procedural care threaten the ability of independent practices to maintain staffing, invest in clinical infrastructure, and provide timely access to skin cancer treatment. Please protect Medicare beneficiaries’ access to efficient, physician-led dermatologic and Mohs surgical care by reconsidering these proposals. Respectfully submitted, Corey DeWitt, MD Mohs Surgeon and Dermatologist Skin Cancer Center of Northern Virginia Dermatology Center of Winchester Virginia