Objective:

To outline changes in the proposed 2027 Physician Fee Schedule (PFS) that would affect Medicare physician payment rates and reimbursement policies for evaluation and management (E/M) services.

Approach:

• Proposed Changes: The CMS proposal includes reductions in payment for same-day evaluation and management (E/M) visits performed on the same day as procedures with a 0-, 10-, or 90-day global period.
• Impact on Retina Practices: The proposal specifically affects intravitreal injections, which have a 0-day global period, leading to reduced reimbursement for office visits on the same day as an injection.
• Payment Structure: Under the proposal, the higher-valued service would be reimbursed at 100%, while additional same-day E/M services would be reimbursed at 50%.
• Stakeholder Reactions: ASRS CEO Jill Blim criticized the proposal as a major reduction in reimbursement and expressed disappointment over CMS's approach to modifier 25 discussions.

Key Findings:

• The proposed changes are intended to address perceived duplicative payments.
• Qualifying alternative payment model participants would see a decrease in their conversion factor.
• The proposal includes new restrictions on remote monitoring services and a transition to a revised practice expense methodology.

Interpretation:

Limitations:

• The proposal is subject to public comment and final rule publication before implementation.
• Concerns raised by medical associations may not be addressed in the final rule.

Conclusion:

The proposed rule is set to take effect on January 1, 2027, pending public feedback.

Sources:

• American Society of Retina Specialists
• American Medical Association
• American Academy of Ophthalmology