On July 14, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule and fact sheet for CY 2027 (CMS-1848-P). This rule updates payment policies and payment rates for Part B services furnished under the MPFS. The data files including Addendum B, which lists the proposed RVUs for each CPT^® code can be found here. Comments are due September 14.

With the release of this rule, CMS signals the possibility of moving away from the AMA CPT and RUC process by creating or proposing several new HCPCS G code replacing CPT codes for payment in the Medicare program. Coinciding with the creation of new HCPCS G codes, the agency also outlines a request for information (RFI) asking stakeholders to provide information on the use of CPT codes for physician payment and if the use of CPT codes creates a payment system with contradictory incentives. This proposed rule also contains several other formal RFIs including ways to improve primary care and seeking improved payment methodologies for the global surgical package.

Throughout the rule, CMS seeks comments on many of its proposals. While not unusual to seek comment on specific topics, the CY 2027 rule offers many more opportunities for stakeholders to weigh in on proposed policies. Finally, the Make America Healthy Again initiative, a priority of the administration, is prominent throughout with discussions on primary care, improving chronic care management, and creation of new HCPCS codes to support such care.

Note that the page numbers listed in this document refer to the display copy of the proposed rule. Additionally, new CPT codes do not have final code numbers assigned. The complete code numbers will be provided when the final rule is released in early November.

Regulatory Impact Analysis  

Highlight: Payment for services paid under Medicare will decrease for some specialties while increasing for others.

Conversion Factor for 2027 – p. 1,144

For the second year, there are two separate conversion factors, one for practitioners participating in a qualifying advanced alterative payment model (APM) and the other for those not participating in a qualifying APM. The qualifying APM conversion factor is $33.17, a decrease of 1.19%, and the non-qualifying APM conversion factor is $32.84, a decrease of 1.68%. Decreases of the two conversation factors are due to Congress only providing a one-year conversion factor increase of 2.5% for CY 2026; therefore, current law requires a 2.5% reduction to Medicare payments in 2027.

Specialty Level Impact of the Proposed Policy Changes – p. 1,154

CMS attributes the impact of the proposed policies to be generally related to changes in relative value units (RVUs) redistribution resulting in changes to work RVUs for new and revised codes. Additionally, CMS’s proposed change to HCPCS code G2211 (longitudinal, complex patient care), updates to payment for services when performed on the same day as 0-, 10, or 90-day global procedure, and other code-level updates impact the increases or decreases to Medicare payments per specialty.

Table D-B5, page 1,146 of the rule (Appendix A of this summary) estimates the specialty level impacts of the policies included in the proposed rule and includes impacts of rate-setting changes and changes to RVUs within the budget neutral system. For the specialty of urology Medicare payments are expected to decrease by approximately 2%. The impact of the proposed rule’s policies on group practices and individual physicians varies based on practice type and the mix of patients and services provided to those patients.

Global Surgical Packages – p. 57

Highlight: The agency continues to keep the global surgical package top of mind, seeking comment on ways to improve payment.

CMS proposes to pause the global surgical package data collection required under section 523 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and to revise the process to improve

global surgical service valuation and payment accuracy. The agency believes that the current data collection on global services is burdensome to providers and seeks comment on ways to collect data to more accurately value payment for global surgical services. Specifically, CMS requests feedback on how to develop methodologies that better identify and, where appropriate, separate the individual components included in global surgical packages. CMS also requests input on approaches to "right-size" payment for global packages so that reimbursement more accurately reflects current clinical practice and resource costs while improving transparency around differences in costs and value across sites of care.

As with prior years, CMS continues to examine payment associated with the concept of the global surgical package. The global surgical package, also known as the global period or simply the globals, is a billing and payment concept used by Medicare to provide a single, flat payment made for all care associated with a surgical procedure which includes pre-operative and post-operative E/M visits, and payment for the surgery.

Updates to Practice Expense Methodology - p. 49

Highlight: CMS continues to tweak payment methodology by removing steps in the payment formula that CMS believes rely on outdated data.

CMS proposes to simplify the methodology used to calculate PE RVUs, a change that could meaningfully redistribute Medicare payments across specialties. Currently, PE RVUs are determined through an 18-step process that includes the Indirect Practice Cost Index (IPCI), which adjusts indirect practice expenses based on specialty-level survey data. CMS proposes removing the IPCI entirely, eliminating steps 12 through 17 of the payment formula methodology.

CMS believes the IPCI relies too heavily on outdated, specialty-specific survey data and can distort code-level valuations by overriding more current and precise resource inputs. The agency argues that eliminating the IPCI will produce more accurate PE valuations that better reflect the resources required to furnish individual services. To lessen the impact on physician payments, CMS proposes a two-year transition, with half of the IPCI adjustment removed in the first year and the remaining adjustment eliminated in the second year.

CMS also seeks stakeholder feedback on additional changes to the physician practice expense (PE) methodology following its CY 2026 final policy reducing indirect facility PE relative value units (RVUs) to 50% of the non-facility allocation. CMS describes the CY 2026 change as an initial step to address longstanding distortions in indirect PE payments across sites of care, and the agency indicates it is considering further refinements for rulemaking.

Specifically, CMS is requesting information on how indirect practice expenses differ across physician practice arrangements, particularly for physicians employed by hospitals or health systems. The agency questions whether hospital-employed physicians incur enough indirect practice expenses to justify the current 50% facility PE allocation and asks whether the appropriate allocation could be even lower—including potentially 0% if those costs are already reflected in hospital outpatient payments under the Hospital Outpatient Prospective Payment System (OPPS).

CMS also seeks comment on potential approaches to better identify hospital-employed physicians, including whether a new HCPCS modifier could distinguish services furnished by employed clinicians and allow more accurate allocation of indirect PE RVUs. More broadly, CMS requests objective data on physician employment arrangements, practice costs, and payment relationships to inform future refinements to PE valuation and ensure Medicare payments more accurately reflect the resources required to furnish services across different sites of care.

Payment for Medicare Telehealth Services under Section 1834(m) of the Act – p. 60

Highlight: CMS implements telehealth flexibilities and revises policy for virtual presence for teaching physicians.

Changes to the Medicare Telehealth Services List

CMS did not receive any requests to add or remove services from the Medicare Telehealth Services List for CY 2027. Any requests for changes for CY 2028 must be submitted to and received by CMS by February 10, 2027.

Telehealth Flexibilities and Modifiers

Congress recently extended Medicare telehealth flexibilities through Section 6209(a) of the Consolidated Appropriations Act (CAA), which removed the geographic restrictions, expanded the list of acceptable originating sites and expanded the providers eligible to furnish telehealth services until December 31, 2027.

Section 6209(g) of the CAA required CMS to establish modifiers for telehealth services in certain instances, starting on January 1, 2027. While these modifiers do not affect payment, they are required for telehealth service claims furnished through a telehealth platform with whom the physician has a contractual relationship, or when telehealth services are furnished incident to a physician or practitioner’s professional service. To implement this provision, CMS created modifiers BB and BC; further guidance on utilization of the modifiers will be available on the CMS website.

Telehealth Critical Care Consultations

In the CY 2026 MPFS final rule, CMS permanently removed the frequency limitation of one critical care consultation service furnished by telehealth per day. To align the code descriptors with this policy, CMS proposes to revise the descriptors to remove “initial” from G0508 and “subsequent” from G0509. The proposed new code descriptors are as follows:

• G0508: Telehealth consultation, critical care; first 30 to 74 minutes.
• G0509: Telehealth consultation, critical care; each additional 30 minutes (List separately in addition to code for primary service).

Changes to Teaching Physicians’ Billing for Services Involving Residents or Teaching Physicians with Virtual Presence

Current CMS policy allows teaching physicians to have a virtual presence in all teaching settings, only in clinical instances when the service is a three-way telehealth visit, with the teaching physician, resident and patient in different locations. The agency proposes to revise this policy to allow teaching physicians to bill for services involving residents when either the teaching physician or the resident is in the same physical location as the patient. The agency is assuming that “same physical location” means the same room and seek comment on if this is appropriate. This policy only applies to services on the Medicare Telehealth Services List.

Telehealth Originating Site Facility Fee Payment Amount Proposed Update

CMS proposes to set the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) at $32.65. This change is based on the proposed percentage increase in MEI and will be updated in the final rule.

Valuation of Specific Codes – p. 84

Each year, CMS receives work and practice expense RVU recommendations from the AMA RUC for new and revised CPT codes. The agency reviews these recommendations for inclusion in the fee schedule. Additionally, with this rule CMS has reviewed and revised code valuations that were not a part of the RUC recommendations for this rule cycle, including remote therapeutic monitoring and remote physiologic monitoring.

Prostate Biopsy Services (CPT codes 55705, 55707, 55708, 55709, 55710, 55711, 55712, 55714, and 55715) – p. 113 

The AUA was instrumental in revising the prostate biopsy code set yet again to reflect current clinical practice for prostate biopsy services after two codes, 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) and CPT code 76872 (Ultrasound, transrectal;) were referred to the CPT Editorial Panel for revisions. The CPT Editorial Panel deleted CPT code 55700 and created a family of CPT codes to more accurately reflect the various types of approaches for performing a prostate biopsy. For CY 2027, CMS has accepted the RUC reaffirmed work values and PE inputs for all the codes except for new code 5XX14 (Biopsy, prostate, transrectal or transperineal, including imaging guidance, fusion-targeted lesion(s) without regional; each additional targeted lesion (List separately in addition to code for primary procedure).

For new code 5XX14, CMS disagrees with the RUC-recommended work RVU of 0.80, and instead proposes a work RVU of 0.68. CMS bases this proposed value by crosswalking the service to CPT code 93567 (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure)). The agency believes that crosswalking to this service will help maintain relatively among codes with similar time values. Although the code was surveyed with only 6 minutes of total work time, the RUC recommended valuation results in an intensity nearly three times greater than the related add-on code 55715, which has 35 minutes of work time and a work RVU of 1.80. CMS also found no comparable add-on codes in the RUC database with such a high work RVU for codes with similar times. While acknowledging that CPT code 55X14 is technically difficult and intensive, CMS believes the proposed valuation does not maintain appropriate relativity with similar services under the MPFS.

Biofeedback Training (CPT codes 90901, 90X03, 90912, and 90913) – p. 123

Existing CPT codes 90901, 90912, and 90913, and new code 90X03 underwent an AMA RUC survey in the fall of 2025, and the findings were presented at the January 2026 AMA RUC Meeting. Of particular interest to the AUA are CPT codes 90912 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient), and 90913 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)). CMS proposes to accept the RUC recommended work RVUs of 0.90 for CPT code 90912, and 0.50 for CPT code 90913. CMS also proposed to accept all the practice expense inputs recommended by the AMA RUC.

Remote Monitoring (CPT codes 98975, 98976, 98977, 98978, 98980, 98981, 98984, 98985, 98986, 98979, 99091, 99453, 99454, 99457, 99458, 99473, 99474, 99445, and 99470) – p. 149

At the September 2024 CPT Editorial Panel meeting, several revisions were made to the remote monitoring services code set to increase flexibility in reporting these services and to better align with current clinical practice. The revisions created new codes while clarifying descriptors and coding requirements for others. Payment amounts and practice expense inputs were finalized and implemented beginning January 1, 2026.

CMS proposes several significant policy changes for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services which, if finalized, will be effective January 1, 2027. The policy changes, per CMS are intended to strengthen clinical oversight, reinforce the practitioner-patient relationship, and address program integrity concerns identified by the Office of Inspector General (OIG).[1]

Citing the need for appropriate use and billing of RPM and RTM services, CMS proposes that practitioners who provide RTM and RPM services must first conduct a separately reportable initiating visit prior to starting RTM and RPM. The initiating visit may be conducted either in-person or via telehealth and the use of RTM and RPM must be discussed with the patient and the patient’s consent must be obtained prior to starting RTM and RPM.

Additionally, CMS proposes to require that RTM services be furnished only to an established patient, aligning RTM with existing RPM policy. The agency believes practitioners should have an existing clinical relationship with the patient, including knowledge of the patient's medical history and current health status, before ordering RTM services and then using the collected data to guide treatment. CMS notes that this proposal is also intended to address OIG findings that some providers billed remote monitoring services for patients with whom they had no prior clinical relationship.

CMS proposes that CMS will only provide payment for RTM and RPM services when the services are provided by clinical staff employed by the physician or practice. That is, to count the time spent by clinical staff when providing RTM or RPM services, the clinical staff cannot be employed by a third party contractor, and the clinical staff must be a “direct employee of the practitioner or practitioner’s practice.” CMS clarifies that the clinical staff do not have to be physically located within the practice, nor does the beneficiary need to be on-site. CMS believes that third party outsourced RTM and RPM services leads to fragmented care, particularly given the third party has little to no connection to the patient, nor is there appropriate oversight and supervision of the provision of the services. Of note, CMS is seeking comment on how often third parties provide RTM and RPM services, and whether the proposal, if finalized, may affect Medicare beneficiary access to these services.

Finally, to reduce administrative burden, improve care coordination and reduce fraud, waste and abuse, CMS seeks comment on a policy option that would create four remote monitoring HCPCS codes to replace the seventeen RTM and RPM CPT codes for purposes of Medicare billing and payment. The agency believes, backed by the OIG report, that many Medicare beneficiaries do not receive treatment management services when receiving RTM or RPM services. The G code options which CMS is seeking comment on reflect this lack of care by creating a requirement within the codes for “ treatment management services, requiring at least one real-time interactive communication with the patient or caregiver; time totaling at least 20 minutes.”

CMS seeks comment on the following policy option for G Codes for RTM and RPM Code Descriptors:

• GRPM1: RPM initial set-up and patient education.
• GRPM2: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure,

pulse oximetry, respiratory flow rate), per calendar month, including:

• Device(s) supply with daily recording(s) or programmed alert(s) transmission.
• 2 or more days of data transmission.
• Treatment management services, requiring at least one real-time interactive communication with the patient/caregiver; time totaling at least 20 minutes.

• GRTM1: RTM initial set-up and patient education.
• GRTM2: Remote monitoring of therapeutic parameter(s) (eg, therapy adherence, therapy response, digital therapeutic intervention), per calendar month, including:
  • Device(s) supply for data access or data transmissions.
  • 2 or more days of data transmission.
  • Treatment management services, requiring at least one real-time interactive communication with the patient or caregiver; time totaling at least 20 minutes.

Revision of G2211 with Modifier MOD1 – p. 170

Highlight: G2211 slated to be replaced by a modifier, retaining the description of the service, but changing the payment rate.

The agency proposes to delete code G2211 (Visit complexity inherent to evaluation and management associated with medical care services) and create a modifier to take its place.^[2] The modifier, MOD1, will have the exact same descriptor as G2211, and per the agency should be reported and billed in the same way as the G-code, except the new modifier is placed on the same claim-line as the CPT code for the evaluation and management (E/M) service.

The modifier, when appended to an appropriate E/M code, will increase payment by 16% of the value of the reported E/M CPT code. CMS believes the clinical resources associated with providing longitudinal, relationship-based care are inherent to the provided E/M service rather than as distinct service requiring a separate add-on code. CMS states that using a modifier instead of a separate code will more accurately reflect the work associated with this care and will also simplify billing by eliminating the need for an additional claim line, thereby reducing administrative burden. Table A-D7 on page 172 provides an illustrative example of how payment levels will change when the new modifier is reported with an E/M code. For example, when a lower level E/M service is provided such as 99212 (established patient E/M service), payment will increase by 29%.

G2211 in Medicare Accountable Care Organizations (MOD2) – p. 173

CMS proposes to replace HCPCS G2211 office visit complexity add-on code, when used in the Shared Savings Program ACOs, with a new claims modifier (MOD2) that would pay 32% of the associated evaluation and management (E/M) visit (twice the payment of MOD1) to better account for the added complexity of caring for patients in the ACO setting. The enhanced payment is intended to recognize the additional time and effort required to provide coordinated, longitudinal, whole-person care.

Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods and Changes to Payment When Modifier 25 is Used – p. 199

Highlight: CMS reduces payment for services performed on the same day.

CMS proposes to reduce payment when a separately identifiable office/outpatient evaluation and management (E/M) visit as indicated by modifier -25,  is furnished by the same physician (or a physician in the same practice) on the same day as the procedure included in a 0-, 10-, or 90-day global. The most expensive service (either surgical procedure or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit furnished on the same day would be paid at 50%. This policy will affect physicians who provide an E/M service coupled with a same day procedure.

The agency seeks comment on whether a different reduction, such as 25%, would be more appropriate.

CMS also requests feedback on whether this policy should be expanded beyond office/outpatient E/M visits to include other E/M services, such as inpatient visits. Finally, the agency also notes that they will monitor for abuse of the policy by tracking if providers are scheduling services on separate days solely to maximize payment.

Comment Solicitation on Payment for Physician-Patient Clinical Trial Discussions – p. 214

Highlight: To help improve clinical trial participation, CMS proposes code to pay for patient and physician discussions regarding clinical trials.

The agency seeks comments on the potential development of a HCPCS G-code to capture the time, effort, work, and resources associated with physician/patient conversations regarding participation in clinical trials. CMS states that, despite significant federal investment in biomedical research, adult cancer patient enrollment in clinical trials remains below 7 percent. Per the agency, major yet modifiable barrier to clinical trial enrollment is that physicians rarely initiate these discussions. As noted in the rule, “national survey data show that 70 percent of oncologists discuss trials with less than a quarter of their patients, yet more than 50 percent of eligible patients enroll when actively offered a clinical trial.”

The primary barrier to these discussions is the time and administrative burden on physicians, which is not currently captured as a specific element in the E/M CPT code family. To address this, CMS seeks comments on a possible solution that creates a new HCPCS G-code to reimburse physicians (or other qualified healthcare professionals) for spending a minimum of 20 minutes counseling patients on clinical trial eligibility, options, risks, and benefits. While the code has not been officially proposed, CMS does seek comment on a work RVU between 1.00 and 1.50, whether the service may be provided a telehealth service, and CMS requests suggestions as to the types of documentation that would be required to bill for the service.

Potentially Misvalued Services Under the Physician Fee Schedule – p. 232

Each year the agency reviews potentially misvalued services. The criteria to identify a misvalued service are applied at the code level, and refinements are proposed by CMS for each code deemed misvalued by the agency. Beginning in 2012, CMS finalized a process for the public to nominate potentially misvalued services. Nominations for potentially misvalued services are due to the agency by February 10 each year and requestors must submit documentation supporting the code nomination. For a complete list of the types of supporting documentation that is acceptable please see page 235 of the display copy of the proposed rule. Finally, the review of values for the CPT code set is required by law, and since 2009, CMS has reviewed more than 1,700 codes.

Urethral Bulking Agent Material (CPT Code 51715) – p. 237

CMS proposes to update the practice expense valuation for CPT code 51715 (Endoscopic injection of implant material into the urethra and/or bladder neck) to better reflect current clinical practice in the office setting.

Medical Technology Partners requested that CMS recognize the cost of the urethral bulking implant material, noting that the current valuation does not include this essential supply, creating a barrier to furnishing the procedure in the non-facility setting. Based on the submitted pricing information and the fact that the code has not been comprehensively reviewed since the 1990s, CMS proposes to create a new direct practice expense supply code SD396, representing a 2 mL vial of urethral bulking agent, priced at $1,175. CMS also proposes to include one unit of this supply in the non-facility practice expense inputs for CPT code 51715.

Given the significant cost of the implant and the length of time since the code was last reviewed, CMS also seeks comment on whether CPT code 51715 should be referred to the RUC for review to determine if the service needs to be resurveyed.

Complex Cystogram (CPT Codes 57128 and 51229) – p, 238

CMS received a request to increase the pricing of three direct practice expense supply items used in complex cystometrogram procedures (CPT codes 51728 and 51729): SD017 (catheter balloon), SD027 (catheter pressure), and SD131 (tubing pressure). The requestor, Laborie Medical Technologies, submitted invoices from January 2025 to October 2025, proposing substantial price increases for each supply.

CMS states that it will not make any changes to the practice expense inputs for these services. The agency notes that it previously reviewed the same request in the CY 2026 PFS final rule and determined that the submitted invoices could not be matched to the existing Medicare supply items because the product descriptions differed from the established supply code descriptions. The newly submitted invoices continue to reference products with different names, and no additional information was provided to demonstrate that they represent the same supplies currently recognized in the practice expense database. As a result, CMS is maintaining the existing pricing for these supply items, citing insufficient evidence to verify that the requested invoices correspond to the Medicare practice expense supply codes.

Request for Information: Redesigning Primary Care to Make America Health Again – p. 252

Highlight: CMS seeks feedback on modernizing primary care payment to better support preventive care and technology-enabled services.

CMS requests stakeholder feedback on how Medicare should modernize the payment and valuation of primary care services under the PFS. The agency states that primary care is central to HHS’s “Make America Healthy Again” (MAHA) priorities and emphasizes that current payment policies should better support preventive, high-value care while reducing long-term health care costs associated with chronic disease.

According to CMS, the current valuation of primary care services was established when care was primarily delivered through traditional office-based visits. The agency notes that advances in digital health technologies and artificial intelligence (AI) are changing how beneficiaries access medical information and how primary care clinicians deliver care. As a result, CMS is evaluating whether existing fee-for-service payment policies, including office/outpatient evaluation and management (E/M) visits, annual wellness visits, and care management services, continue to appropriately reflect the time, intensity, and value of primary care services.

CMS also highlights its continued interest in expanding prospective primary care payment models. Building on lessons learned from CMS Innovation Center demonstrations and the establishment of Advanced Primary Care Management (APCM) services in the CY 2025 PFS, the agency is considering whether prospective monthly payments could be more broadly incorporated into the Medicare Shared Savings Program and, potentially, original Medicare. CMS notes that any future payment model would need appropriate safeguards to prevent fraud, waste, and abuse, particularly as technology-enabled care becomes more common.

Given the broad scope of this discussion, CMS seeks comments on several overarching policy issues, including:

• Whether primary care services are appropriately valued under the current Physician Fee Schedule and how payment for office visits, annual wellness visits, and care management services could be improved.
• How Medicare should account for technology-enabled care, including digital health tools and AI, when determining payment, service valuation, and evidence of improved patient outcomes.
• How prospective primary care payment models should be implemented within the Medicare Shared Savings Program and whether they should be expanded more broadly across Medicare, including appropriate payment structures and program safeguards.

Reconsidering Relative Primary Care Payment in the Medicare Physician Fee Schedule – p. 255

Highlight: CMS considers restructuring evaluation and management (E/M) payments to better recognize longitudinal primary care.

CMS seeks feedback on whether the current office/outpatient (O/O) evaluation and management (E/M) visit structure appropriately reflects the resources and complexity involved in providing primary care, particularly for patients who require ongoing, coordinated care. The agency notes that traditional E/M codes do not distinguish between different types of visits, such as one-time acute visits, specialty consultations, and longitudinal care provided through an ongoing relationship between a patient and clinician.

According to CMS, the current payment structure may not fully account for the additional work associated with longitudinal primary care, including care coordination, preventive services, and activities that occur outside of face-to-face visits. The agency notes that specialties relying heavily on E/M services, including primary care, may receive different payment levels than specialties that routinely provide procedural services or diagnostic testing. CMS previously took steps to better recognize the complexity of longitudinal care through the adoption of HCPCS code G2211, an add-on payment for visits where the clinician serves as the continuing focal point for a patient’s health care needs.

However, CMS states that the current E/M code set may still insufficiently reflect differences in the nature and intensity of care provided. As a result, the agency is considering whether future payment policies should establish separate categories of O/O E/M visits based on the purpose of the encounter, including:

• Longitudinal care visits, which involve an ongoing patient-clinician relationship and include care delivered during and between visits, such as chronic disease management, preventive care, and care coordination.
• Acute care visits, which focus on evaluating and treating a specific, short-term medical issue.
• Consultative visits, which are performed in response to a referral to address a specific clinical question and provide recommendations back to another practitioner.

CMS seeks feedback on how to better recognize the differences among longitudinal, acute, and consultative care within the MPFS. The agency requests input on whether existing coding structures should be modified or whether new codes should be created, how longitudinal care should be valued, whether care management services should be incorporated into payment, and what data should inform future valuation decisions.

Care Management Code Family – p. 258

Highlight: CMS seeks feedback on restructuring care management payments to improve utilization and account for technology-enabled care models.

CMS seeks feedback on how to improve the utilization and effectiveness of care management services, which are intended to support ongoing care coordination, chronic disease management, and other activities provided between patient visits. Over the past 14 years, CMS has expanded separate payment pathways for care management services that were previously considered part of evaluation and management (E/M) visits, including Transitional Care Management (TCM), Chronic Care Management (CCM), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) services. See Table A-E1 below for additional details on current care management services paid under the Physician Fee Schedule.

Despite these efforts, CMS notes that adoption of care management codes has been lower than anticipated. The agency states that stakeholders have identified cost-sharing requirements and documentation burdens as key barriers to broader use. CMS has previously taken steps to address these concerns, including simplifying certain documentation requirements for Chronic Care Management services, but continues to evaluate whether additional changes are needed to make care management services more accessible while maintaining appropriate program integrity safeguards.

CMS is considering whether the current care management code structure should be simplified or redesigned to better reflect the way primary care is delivered, including through team-based care, population health management, and technology-enabled services. The agency requests comment how to best improve the current care management code structure, and seeks feedback on whether new approaches, such as technology-enabled care management codes or a two-track payment model, may be appropriate as digital tools become increasingly integrated into primary care delivery.

Payment Implications of Technology Enablement of Primary Care – p. 261

Highlight: CMS requests feedback on how Medicare should account for technology-enabled primary care and clinical AI in future payment policies.

CMS requests stakeholder feedback on how advances in technology and clinical artificial intelligence (AI) are changing the delivery of primary care and how Medicare payment policies should evolve in response. The agency notes that AI tools are increasingly being used to reduce administrative burden and support clinical decision-making, with technologies such as AI documentation assistants and clinical decision-support tools becoming more widely adopted in physician practices. CMS believes these technologies have the potential to shift primary care from reactive, manual processes to more proactive, data-driven, and personalized care.

According to CMS, technology-enabled care may improve quality while reducing the resources required to deliver certain services. However, the agency notes that the rapidly evolving nature of these technologies, limited information on their costs, and uncertainty regarding their long-term impact present challenges for developing appropriate payment methodologies. As a result, CMS is exploring whether future payment policies should place greater emphasis on demonstrated clinical outcomes rather than traditional fee-for-service valuation.

CMS seeks feedback on the current use of AI and other technology-enabled tools in primary care, including their impact on clinical workflows, physician productivity, resource costs, patient outcomes, and beneficiary experience. The agency also requests input on how Medicare should evaluate the effectiveness of these technologies, protect patient privacy, monitor for fraud, waste, and abuse, and determine whether existing coding and payment policies adequately recognize technology-enabled care. In addition, CMS seeks comments on lessons learned from private payors, appropriate outcomes measures and data reporting approaches, and whether alternative payment models beyond fee-for-service, outcomes-based, or prospective payment may be better suited to support technology-enabled primary care.

The Future of the Care Management Services – pg. 297

Highlight: CMS seeks information on whether the current code structure for care management services is appropriate.

Coupled with the agency’s interest in improving the care management code family as discussed earlier in this summary, CMS is re-evaluating the long-term role of Medicare's care management services, which currently provide separate payment for care delivered between face-to-face visits. The agency is considering whether the current structure of care management codes continues to be the best approach for supporting longitudinal, coordinated care.

CMS notes that care for patients with serious illness extends beyond office or home E/M visits and includes significant non-face-to-face activities, such as care coordination, communication with patients and caregivers, medication management, and collaboration with other clinicians. CMS requests comments on the following:

• How should CMS differentiate the care management requirements for seriously ill beneficiaries from other Medicare beneficiaries?
• What are the essential service elements that must be included?
  • Examples of essential services include continuity with a designated team member, access to timely clinical support, comprehensive symptom and caregiver assessment, electronic care plans, coordination with treating physicians, patient/caregiver education, timely follow up after ED/discharge.
  • What other service elements should be included? Should any not be included?

Current Procedural Terminology (CPT) Request for Information (RFI) – p. 304

Highlight: Coupled with proposals throughout the rule to create HCPCS codes for services paid under the MPFS, CMS requests information on possible avenues to move away from the AMA CPT and RUC processes.

CMS requests stakeholder feedback on whether the current physician coding and valuation system, centered on the AMA's CPT coding system and the AMA Relative Value Scale Update Committee,(RUC) continues to be the best option for payment Medicare services. CMS acknowledges that CPT codes and the RUC have formed the foundation of physician payment under the MPFS for many years, but the agency raises its longstanding concerns about reliance on a private organization, the AMA, to develop and value codes that directly influence physician reimbursement.

HIPAA regulations designated the combination of HCPCS and CPT codes as the national standard for reporting on claims, physician and other health care services. The agency believes that the HIPAA statute does not specifically mandate the use of CPT codes in HIPAA transactions stating that “there is no specification in the HIPAA statute regarding the manner in which these national coding sets may be used or how they may be combined, and only HHS interpretation, not the Act itself, mentions CPT, which suggests that the agency believes there may be flexibility to reconsider the current coding framework used in  the Medicare program.

CMS also states in the rule “we note the historic reliance on the CPT and RUC process as a potential contributor to the development of US health care as a ‘sick care‘ system with limited emphasis on prevention and lifestyle modifications and which may inhibit progress on the Secretarial priority to Make America Healthy Again.” The agency suggests that the existing coding and valuation process may have contributed to a health care system that prioritizes treatment of illness over prevention and broader population health goals.

CMS seeks public comment on the following questions, copied directly from the proposed rule:

1. What, if any, evidence is there for CMS to consider regarding the harms or challenges associated with AMA’s monopoly over CPT-4 licenses for health care entities? Please cite potential improvements to patient care diverted or delayed due to AMA’s monopoly over CPT codes, including inhibited innovations and acquisition or maintenance costs of CPT® licensure.
2. What, if any, evidence is there that the generation of CPT-4 codes follows a process of identification of medical necessity? What opportunities or examples from other populations, sites of care, or international health systems could instruct a process of identification of medical necessity in the CPT-4 code development process?
3. A combination of CPT-4 and HCPCS codes were formally adopted by HHS as the legal standard for national coding for physician and other services as part of implementing HIPAA (45 CFR 162.1002(a)(5)). If CMS were to revisit this standard in future rulemaking, which if any alternatives exist to CPT-4 for CMS to consider as part of the national coding standard for physician services? Would CMS need to specify a separate legal standard, or could CMS allow for private competition to supplement the existing CPT-4 coding standard?
4. What objective alternatives exist, or could be developed, to maintain a more objective process to the current AMA CPT and RUC committee processes? How would these alternatives support or inhibit innovation?
5. What are the benefits and drawbacks of paying for physician procedural services based on the underlying International Classification of Diseases, 10th Revision (ICD-10) procedure code, as an alternative to CPT-4 code? How could the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) services be grouped or bundled into payment categories, similar to Medicare Severity Diagnosis Related Groups (MS- DRGs), or Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classifications (APCs)? What other alternatives exist for bundling or grouping procedural services?

This request for information represents one of CMS's broadest requests for information on the Medicare physician coding and payment processes. The RFI also coincides with CMS proposing changes to, or requesting feedback on, several CPT code families whereby the agency wants to create HCPCS G-codes to replace CPT codes for use in the Medicare program.

Limiting Medicare Coverage of Certain Individuals – p. 454

Highlight: CMS proposes Medicare enrollment changes to implement new statutory citizenship and immigration eligibility requirements.

 

CMS proposes to update Medicare enrollment policies to implement section 1899C of the Social Security Act, which was added by the Working Families Tax Cut (WFTC) legislation enacted on July 4, 2025. Under the new law, Medicare eligibility is limited to four categories of individuals: U.S. citizens or nationals, lawful permanent residents, Cuban and Haitian entrants, and individuals lawfully residing in the United States under a Compact of Free Association (COFA).

Prior to enactment of the WFTC legislation, Medicare generally relied on the same lawful presence verification process used by the Social Security Administration (SSA) for Title II benefits. Under that framework, a broader range of noncitizens who were lawfully present in the United States, such as refugees, asylees, and certain parolees, could qualify for Medicare if they met all other eligibility requirements. Since the WFTC legislation narrows Medicare eligibility without changing Title II eligibility requirements, the previous verification process is no longer sufficient for determining Medicare eligibility. Therefore, CMS proposes to establish Medicare-specific definitions and enrollment policies related to citizenship, nationality, and immigration status to ensure compliance with the new statutory eligibility requirements.

Medicare Prescription Drug Inflation Rebate Program – p. 480

Highlight: CMS proposes policies to implement the Medicare Prescription Drug Inflation Rebate Program.

Overview of the Medicare Prescription Drug Inflation Rebate Program

Sections 11101 and 11102 of the Inflation Reduction Act established requirements that drug manufacturers must pay inflation rebates if they raise their prices for certain drugs payable under Part B and/or covered under Part D faster than the rate of inflation.

Summary of Proposed Policies for the Medicare Prescription Drug Inflation Rebate Program

CMS proposes the following new policies to implement the Medicare Part B Drug Inflation Rebate Program:

• Clarify the definition of “first marketed date” to clarify the data sources that the agency would use to identify the first marketed date when relevant ASP data is not available;
• Revise the skin substitutes excluded product category for Part B rebatable drugs to only apply to certain skin substitutes; and
• Clarify the CPI-U data that would be used to determine the benchmark period CPI-U in place of the month when CPI-U data is not available.

CMS proposes the following new policies to implement the Medicare Part D Drug Inflation Rebate Program:

• Clarify definitions of applicable period CPI-U and what CPI-U data would be used when data from the first month is not available; and
• Require providers and suppliers who are covered entities to submit Part D 340B data to the 340B repository beginning with claims on or after January 1, 2027.

Appendix A: Table D-B5 CY 2027 PFS Estimated Impact on Total Allowed Charges by Specialty – p. 1,146

 

 

 

 

[1] HHS-OIG: Additional Oversight of Remote Patient Monitoring in Medicare Is Needed: https://oig.hhs.gov/reports/all/2024/additional-oversight-of-remote-patient-monitoring-in-medicare-is-needed/

[2] HCPCS code G2211 full description: Visit complexity inherent to new or established office/outpatient or home or residence evaluation and management service, associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.