Comment on CMS-2026-2377-0002

Docket: CMS-2026-2377 (CY 2027 Physician Fee Schedule Proposed Rule) Subject: Expansion of the Primary Care Exception to Include All Office/Outpatient E/M Services, Including 99214 and 99215 I am submitting this comment as a Designated Institutional Official (DIO) and academic physician leader responsible for oversight of multiple ACGME-accredited graduate medical education programs, including Family Medicine and Internal Medicine residencies with ambulatory continuity clinic training sites. I support CMS's proposal to expand the Primary Care Exception (PCE) to allow all office and outpatient evaluation and management (E/M) services, including higher-complexity visits represented by CPT codes 99214 and 99215, to be furnished under the exception when the teaching physician determines such care is clinically appropriate. This proposal appropriately recognizes the realities of modern primary care practice and residency education. In many residency continuity clinics, residents care for older adults and medically complex patients with multiple chronic conditions, behavioral health comorbidities, polypharmacy, and significant social determinants of health challenges. These patient populations frequently require care that legitimately meets higher levels of medical decision-making. Current PCE limitations do not always align with the complexity of patients seen in academic primary care practices. The proposed change would support the educational principle of graduated responsibility that is fundamental to residency training. Senior residents, particularly in Family Medicine and Internal Medicine, should develop increasing autonomy in the management of complex ambulatory patients while maintaining appropriate faculty supervision. This proposal better reflects the skill level and responsibilities of advanced residents preparing for independent practice. The proposal may also improve patient access and clinic efficiency. Residency clinics frequently serve as an important source of primary care for Medicare beneficiaries and other underserved populations. Allowing greater flexibility in supervision requirements for clinically appropriate encounters may reduce operational bottlenecks while preserving physician oversight and accountability. Additionally, many academic primary care practices face significant financial pressures. Allowing reimbursement to more accurately reflect the complexity of patients being treated may improve the sustainability of residency continuity clinics and support continued investment in physician workforce development, faculty engagement, quality improvement, and patient care services. While I support the proposal, I encourage CMS to recognize a potential unintended consequence. Increased flexibility should not inadvertently reduce direct faculty observation, mentorship, or clinical coaching. Some of the most valuable educational experiences in residency occur when faculty and residents jointly manage complex patients. Programs should continue to employ competency-based supervision models that account for resident experience, patient complexity, and individual learner needs. Accordingly, I recommend that CMS: 1.Finalize the proposed expansion of the Primary Care Exception to include all office and outpatient E/M levels. 2.Retain clear language emphasizing teaching physician discretion regarding clinical appropriateness and resident readiness. 3.Clarify that the policy is intended to increase flexibility without discouraging direct observation, faculty teaching, or progressive supervision practices. 4.Provide additional compliance and documentation guidance for higher-complexity visits furnished under the exception. 5.Monitor implementation to assess effects on patient access, educational outcomes, and quality of care. In summary, I believe this proposal represents a thoughtful modernization of Medicare policy that better reflects contemporary primary care training and practice. If implemented carefully, it has the potential to strengthen resident education, improve access to care, and enhance the sustainability of academic primary care clinics while maintaining appropriate clinical oversight. John Vanschagen, MD, FAAFP Designated Institutional Official Regional Chief Academic Officer Trinity Health West Michigan