Comment on CMS-2026-2377-0002

I am submitting comments regarding the proposed CY 2027 Physician Fee Schedule policy, and reducing reimbursement when a separately identifiable Evaluation and Management EM service and procedure are performed on the same day. While I understand CMS’s goal of reducing perceived payment duplication, I believe this proposal does not reflect the realities of outpatient medicine, particularly in dermatology where evaluation and procedures are frequently intertwined. My practice will continue to comply with Medicare regulations, CPT requirements, NCCI policies, documentation standards, and medical necessity requirements. However, this policy will predictably alter physician workflow. If finalized, this policy creates a financial incentive to separate E/M services from procedures whenever feasible. Patients requiring procedures would now return on a separate day rather than receiving both services in one encounter. This is the foreseeable response to the reimbursement policy while remaining compliant with Medicare requirements. The consequences for regional patients will be substantial. Many travel long distances, including by ferry from the San Juan Islands. Additional visits will increase travel burdens, delay care, increase costs, and increase reliance on telehealth. I wish to formally document, before implementation of this proposal, my expectation regarding its foreseeable operational consequences. I am making these observations contemporaneously so there is a clear record that these utilization changes were predicted and communicated to CMS before implementation. I intend to retain this submission as part of my practice’s compliance documentation. Separating E/M services from procedures will necessarily create additional patient encounters. Those encounters will create additional opportunities for patients to present new symptoms, changing lesions, medication concerns, or other problems requiring physician evaluation, medical decision-making, and documentation. These concerns frequently arise unexpectedly and cannot be predicted when scheduling procedures. CMS should recognize that separating E/M visits from procedures does not eliminate cognitive physician work. It redistributes when that work occurs. A procedure visit may appropriately become an E/M encounter when new medically significant concerns arise. Such services would not represent duplicate billing or attempts to circumvent Medicare policy, but rather the foreseeable consequence of additional encounters. For example, a patient returning for a biopsy may report a new changing lesion or worsening dermatitis requiring evaluation. Medicare rules require those concerns to be evaluated, documented, and, when appropriate, billed separately. Had the biopsy occurred during the initial visit, those issues likely would have been addressed then. One provider in my practice recently completed approximately 280 patient encounters in a month, including about 200 visits appropriately billed with modifier 25. Separating these encounters into EM and procedure visits will create 200 additional encounters, making additional medically necessary E/M services reasonably foreseeable. Separating cognitive evaluation from procedures may predictably change physician behavior. During combined visits, attention is divided among evaluation, counseling, treatment planning, consent, and procedural care. Dedicated procedure visits allow more focused examination, making it foreseeable that additional findings, such as actinic keratoses, suspicious lesions requiring biopsy, or other conditions requiring treatment, will be identified and managed. This may increase both E/M services and procedures due to policy structure, not overutilization or changed billing philosophy. I am documenting these expectations prospectively because I believe they are predictable consequences of this policy. If CMS, Medicare contractors, UPIC, RAC, OIG, or other oversight entities later review utilization changes following implementation, I respectfully request that this submission be considered evidence that these changes were predicted and communicated to CMS before the rule became effective. If future audits identify increases in E/M services or procedures consistent with these workflow changes, such changes should not, standing alone, be interpreted as evidence of abusive billing or attempts to circumvent Medicare policy, but evaluated in the context of the additional encounters created by this reimbursement policy. I respectfully request that CMS reconsider this proposal. While intended to reduce expenditures, I believe it will instead increase patient visits, administrative burden, telehealth utilization, delays in care, and potentially overall Medicare spending while creating hardship for beneficiaries. Medicare policy should encourage efficient, patient-centered care rather than incentivize multiple visits when safe, appropriate care could be delivered in a single encounter.