Our initial alert on the PFS proposed rule concentrated on conversion factors connected to both anesthesia and non-anesthesia services, as well as other issues directly impacting the anesthesia specialty. Today’s alert will focus on provisions in the proposed rule that may occasionally or tangentially affect anesthesia practices. In addition, some of these provisions will directly affect chronic pain providers.
E/M with Procedures
For 2027, CMS is proposing to reduce payment when a separately identifiable office or outpatient evaluation and management (E/M) service is furnished by the same physician (or a physician in the same practice) on the same day as a 0-, 10- or 90-day global procedure. The most expensive service—whether that be the surgical procedure or the E/M—would be paid at 100%, with the remaining service(s) furnished on the same day being paid at the 50% rate.
To be sure, it is rare when both an E/M and procedure are billed by the same provider on the same day for the same patient. This typically occurs only when the E/M represents a service above and beyond the pre-procedure H&P, being reflected by the appending of the -25 modifier. But when these two services are submitted together and are, in fact, deemed medically necessary by the payer, the reimbursement has historically been 100% of the allowable for both the E/M and the procedure. Now, with this proposed rule, one of those two services will drop to 50%—at least where the services are performed in the office or outpatient setting. So, this is more bad news from a reimbursement perspective.
E/M Tracking
In connection with the proposal described immediately above, CMS is (a) considering the future possibility of applying the above 50% policy to inpatient visits, and (b) advising providers that they will be under close watch as to any attempt to maximize payment by scheduling visits in such a way so as to avoid reduced reimbursement. Page 203 of the rule states the following:
While we are proposing to apply this policy only to O/O E/M visits, we are seeking comments on whether it should also apply to other E/M visits, such as inpatient E/M visits. We reiterate that we do not find it appropriate to schedule medical services for patients to maximize payment, which would create undue burden and potential medical risk for beneficiaries. We have a number of data analysis tools to monitor for potentially problematic utilization patterns which may be useful . . . for monitoring for this practice, including distinct claims editing to identify problematic utilization patterns, comparative billing reports to identify to providers their outlier status, and medical review capabilities to determine if the patterns are problematic and indicative of waste or abuse. We are also seeking comment on whether or not it is necessary to revise the conditions of payment to mitigate such payment abuses.
The above appears to indicate that where an E/M service on the same day as a procedure is medically necessary, providers shouldn’t schedule the E/M on a different date just to avoid the 50% reduction in reimbursement. Providers are on notice that CMS will be monitoring inappropriate claim submissions in this regard.
E/M Complexity Add-On
In the 2021 PFS final rule, CMS finalized separate payment for the office/outpatient E/M visit complexity add-on code, HCPCS G2211. You may recall that this code was designed to recognize the extra time, cognitive effort and practice expense involved in managing a patient’s ongoing care over time. It is designed to compensate providers for longitudinal, relationship-based care, which includes proactive management, care coordination and addressing complex or serious conditions on a consistent basis. Policy implementation was temporarily delayed by statute but ultimately implemented in 2025.
For 2027, CMS is proposing two changes:
- Transition HCPCS code G2211 to a modifier that can be appended to the associated E/M base code (the modifier to be determined and disseminated should this proposal be finalized). This modifier would increase the payment of the associated E/M code by 16%, instead of a flat rate, maintaining an equal percentage increase across all levels of E/M codes.
- Recognize additional resource costs incurred by practitioners in Accountable Care Organizations (ACOs) when providing longitudinal care, such as maintaining total cost of care accountability and reporting quality measures that can align with providing longitudinal care and care coordination. Another modifier (to be later identified) would be available to reflect these circumstances but would only be eligible to those practitioners participating in a Shared Savings Program ACO or Participant Providers in a Long-term Enhanced ACO Design (LEAD) Model ACO. The appending of this modifier would increase payment of the associated E/M visit by 32%.
Telehealth Critical Care Consultations
For those anesthesia providers who provide critical care services, you will be interested to know that the American Society of Anesthesiologists is reporting that CMS established 2 new G codes, G0508 (Telehealth consultation, critical care, initial; physicians typically spend 60 minutes communicating with the patient and providers via telehealth) and G0509 (Telehealth consultation, critical care, subsequent; physicians typically spend 50 minutes communicating with the patient and providers via telehealth) to report telehealth consultations for a patient requiring critical care services.
In an upcoming alert concerning the 2027 Medicare PFS proposed rule, we will bring you highlights involving the Quality Payment Program for the coming year. If you have any questions about this article, please reach out to your account executive.