Medicare Modifier 25: Opposition to Automatic Same-Day Payment Reductions
The California Neurology Society (CNS) opposes the automatic payment reduction adopted in the Centers for Medicare & Medicaid Services (CMS) Calendar Year 2027 Medicare Physician Fee Schedule final rule (CMS-1848-F) when a significant, separately identifiable office or outpatient evaluation and management (E/M) service is provided on the same day as a procedure with a 0-day global period. CMS has responded to physician concerns by reducing its originally proposed 50% payment cut to 20% and removing procedures with 10- and 90-day global periods from the policy. CNS acknowledges these changes. Nevertheless, beginning January 1, 2027, the higher-valued eligible service will be paid in full while the lower-valued service will generally be paid at 80%—even when both services are medically necessary and properly documented. The remaining automatic reduction warrants reconsideration.
Fragmented visits burden patients and may increase costs
Many neurological patients have mobility limitations, cannot drive because of seizures, or depend on caregivers and paratransit. Scheduling a separate appointment can mean another trip, caregiver time away from work, additional cost sharing, and greater risk of delayed or missed care. The policy may create financial pressure to separate services that can safely and efficiently be provided together. If that
occurs, Medicare could face additional claims and spending rather than the intended savings. These potential downstream effects should be measured, not assumed away. Neurology is a cognitively intensive specialty, yet many office-based practices also maintain the personnel, supplies, and infrastructure needed to provide procedures. Automatically discounting one legitimate service may disproportionately burden independent practices that lack facility revenue to offset reduced payments. A code-specific analysis is needed to determine whether—and where—duplicated resources actually exist.
Distinct clinical work deserves appropriate recognition
Modifier 25 is used when a patient requires an E/M service that is significant and separately identifiable from the routine evaluation and care already included in a procedure. The modifier does not authorize payment for trivial or duplicated work; documentation must support an independent clinical assessment and medical decision-making. CNS supports accurate coding, appropriate review, and enforcement against improper billing. But the mere fact that two legitimate services occur on one day does not establish that their clinical work overlaps by a fixed 20%. Consider a patient presenting with severe, refractory occipital neuralgia who requires a substantive neurological evaluation, including assessment of symptoms and alternative diagnoses, prior treatment failures, medication safety, and a longer-term management plan. A greater occipital nerve block (CPT 64405, a 0-day global procedure) can be administered during that same visit for immediate pain relief. When the documented E/M service is significant and separately identifiable from the routine care included in the procedure, both services warrant appropriate reimbursement. The finalized policy nevertheless reduces payment for the lower-valued service by 20%. Payment policy should not create financial incentives to delay medically necessary pain relief or require patients to return for care that could appropriately be delivered during a single visit.
CNS position and requested actions
CNS supports correcting any demonstrated overlap through established code-specific valuation and misvalued-code review processes, with participation from the relevant medical specialties. Broad percentage reductions should not substitute for evidence about the actual services and resources involved.
- Reconsider implementation.
CMS should rescind or suspend the finalized 20% reduction pending a transparent, evidence-based, code-specific review.
- Evaluate patient and practice effects.
CMS should assess access to same-day care, transportation burdens, avoidable return visits, beneficiary out-of-pocket costs, independent practice sustainability, and total Medicare expenditures.
- Provide congressional oversight.
California’s members of Congress should seek CMS’s supporting analysis and consider legislative safeguards if the policy threatens appropriate reimbursement or coordinated patient care.
Medicare payment policy should encourage clinically appropriate, coordinated care—not create financial incentives to fragment it.
CNS will continue to monitor implementation of CMS-1848-F and welcomes examples from members concerning legitimate same-day E/M and procedural services. Members may contact the CNS Legislative Committee (LEDGE) at ledge@caneurologysociety.org.
