Comment on CMS-2026-2377-0001

I am a dermatologist in rural Wisconsin writing in opposition to the proposal to reduce payment by 50 percent for the lower-valued service when a separately identifiable office/outpatient E/M visit is furnished on the same day as a 0-, 10-, or 90-day global procedure. I urge CMS not to finalize this proposal in any form: not at 50 percent, and not at the 25 percent alternative on which CMS seeks comment. 1. The 50 percent figure has no empirical basis. CMS's stated justification is that it "aligns with our previous proposal from CY 2019" and "matches the longstanding surgical MPPR." Neither is evidence. Consistency with a proposal CMS declined to finalize, and analogy to a policy built for a different clinical situation, are not measurements of overlap. The surgical MPPR rests on real efficiencies between two procedures in the same operative field at one session: one prep, one drape, shared pre- and post-service work. A significant and separately identifiable E/M visit shares almost none of that. By definition it addresses a problem the procedure does not. Applying a 50 percent cut to a service whose overlap CMS has not quantified is arbitrary. If CMS believes duplication exists, it should measure it and adjust by the measured amount. 2. Modifier -25 is already the safeguard, and RUC valuation already accounts for overlap. CMS's own background section concedes that standalone E/M codes are not billable on the same day as a procedure unless significant and separately identifiable, and that the RUC adjusts for costs it considers duplicative. This proposal therefore discounts twice: once at code-level valuation, again through a blanket reduction. CMS answers that code-level review is "not a practical solution" given thousands of global codes. Administrative inconvenience is not a reason to impose an unmeasured cut on every physician who does the right thing for a patient in a single visit. If CMS lacks resources to value codes accurately, the remedy is to prioritize the high-volume combinations it is actually worried about, not to penalize all of them. 3. The cut lands on the procedure as often as on the visit. Because the reduction applies to the lower-valued service, in many specialties it is the procedure itself paid at half. A biopsy, lesion removal, injection, laceration repair, or drainage does not become half as resource-intensive because the physician also evaluated the patient. The supplies are the same, the staff time is the same, the sterile field is the same, the malpractice exposure is the same. Paying half does not capture an efficiency; it declares the work worth less than CMS's own valuation process concluded it was worth. Both the procedure and the visit should be funded at what they cost to deliver. 4. This is an expansion of the 2019 proposal, not a repeat. The 2019 proposal reached only 0-day globals. This one reaches 0-, 10-, and 90-day globals, and CMS asks whether to extend it to inpatient E/M as well. That is a substantially broader cut than the one commenters rejected and CMS declined to finalize seven years ago, offered without new data showing that the suspected overlap exists or is of this magnitude. The answer to the inpatient question is no, for the same reasons. 5. This threatens access. CMS acknowledges the obvious consequence, a financial incentive to bring patients back on a second day, and then proposes to police it with claims edits, comparative billing reports, and medical review. That is backwards. A payment rule CMS expects to distort scheduling, and plans to audit physicians for responding to, should not be finalized at all. For practices that keep doing it right and treat the problem at the visit where it is found, the arithmetic is simple: we would be paid less than the cost of delivering the care. Independent practices operate on margins that cannot absorb another reduction stacked on a conversion factor that has not kept pace with practice-cost inflation for years. The result will not be efficiency. It will be practices closing their panels to Medicare patients, and beneficiaries in rural and underserved areas, where the small independent practice is often the only practice, making two trips, two copays, and two rounds of travel for care that could have been completed in one visit, if they get it at all. Recommendation: Do not finalize this proposal. If CMS believes resource overlap exists, it should publish the data quantifying it, subject that analysis to notice and comment, and address any true duplication through code-level valuation rather than an across-the-board cut. Thank you for considering these comments.