Coding unchanged
Modifier 25, level on MDM or time [3]
- Still reports a significant, separately identifiable E/M
- Procedure still on its own line with its own global
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Insight · CY2027 Physician Fee Schedule
CY2027 PFS and urgent care: the proposed same-day E/M and procedure cut
Lacerations, abscesses, splints and foreign bodies are an office E/M beside a same-day procedure. The proposal in CMS's words, and a four-step exposure model from your own 835s.
Short answer: when an office E/M and a 0-, 10- or 90-day global procedure are billed the same day by the same group, the most expensive service is paid at 100 percent and every other line at 50 percent [1]. Proposed, not final. Coding does not change; payment does.
CMS-1848-P · 91 FR 43842
Modifier 25 · unchanged
Global 0 / 10 / 90 days
Effective Jan 1, 2027 · if finalized
Edition
Oct 2026
Focus
CY2027 PFS
Audience
Urgent care
Metric
50% lower line
Effective date
Jan 1, 2027, if final
Length
6 min read
50%
Proposed payment for every same-day service except the most expensive one [1]
91 FR43842
CMS-1848-P, published July 16, 2026; comments closed September 14, 2026 [2]
$32.84
Proposed non-QP conversion factor for CY2027, down 1.68 percent [1]
25% alt.
CMS asks whether a smaller adjustment would be appropriate [2]
The example CMS uses, in its own terms
Rationale: resource overlap; CMS believes the current methodology likely duplicates payment [2]. The 50 percent value matches the CY2019 proposal that was not finalized.
99212 with lesion removals 11300 and 11301, same day, same physician [2]
Share of each line's fee-schedule amount. The most expensive service, surgical or E/M, is paid in full; every other same-day line at half.
11301most expensive line
100%paid in full
11300second procedure
50%-50%
99212office E/M, modifier 25
50%-50%
Alternative CMS asked aboutany non-highest line
75%-25% adjustment
025%50%75%100%
Paid at 100%, or the 25% alternativeReduced by 50%, as proposedOffice and outpatient E/M only, as proposed
Same-day pairs the proposal would reach
| Presentation | E/M | Procedure family | What to check in the PFS file |
|---|---|---|---|
| Laceration | 99202 to 99215, mod 25 | Simple and intermediate repair codes | Global days for each repair code you bill |
| Abscess | 99202 to 99215, mod 25 | Incision and drainage codes | Many minor procedures carry 10-day globals |
| Sprain or suspected fracture | 99202 to 99215, mod 25 | Splint and strapping application codes | Confirm whether the code is 0-day |
| Foreign body | 99202 to 99215, mod 25 | Foreign body removal codes by site | Global days by site-specific code |
| Ingrown nail, skin lesion | 99202 to 99215, mod 25 | Nail and lesion procedure codes | CMS's own example uses lesion removal codes |
Do not guess
Global days are a code-level attribute in the PFS relative value file. Pull them for your actual top twenty procedure codes; the exposure model is only as good as that column.
Four steps from your 835s to one number
Inputs: twelve months of Medicare and Medicare Advantage 835s plus the PFS relative value file. Output: last year's book repriced in your own allowed amounts; keep the $32.84 conversion factor in a separate row [1].
- 1List the visitsOffice E/M plus at least one same-date procedure, same group, twelve months
- 2Join to the PFS fileKeep only visits where a procedure carries a 0-, 10- or 90-day global
- 3Rank and halveHighest allowed line at 100 percent; 50 percent of each other line. Sum of reductions = exposure
- 4Express and repeatDivide by last year's Medicare and MA payments; repeat at 25 percent
A payment rule, not a coding rule
Setting does not matter
POS 20
- A facility for unscheduled, ambulatory patients [4]
- The test is same group, same day
Commercial contracts
Read the methodology clause
- Percent-of-Medicare agreements may follow once final
- Own fee schedules will not until amended
Scope to watch
Comment solicitations
- 25 percent instead of 50 percent [2]
- Extension beyond office and outpatient E/M visits
From proposal to January 1
Before the final rule
Run the four-step model at 50 and 25 percentOur urgent care billing services team is running it for clients now.
Mark the contracts that follow Medicare rulesMethodology clause, top ten agreements.
Place it on the scorecardControl four in the 2027 operating manual; revenue per visit on the KPI scorecard.
Test any billing team on itThe build-or-buy math; engagement on the urgent care RCM solution and urgent care RCM pages.
Frequently asked questions
What is the CY2027 same-day E/M and procedure proposal?
CMS proposes that when a separately identifiable office or outpatient E/M visit is furnished by the same physician or group on the same day as a 0-, 10- or 90-day global procedure, the most expensive service is paid at 100 percent and all other services that day at 50 percent. It appears in the CY2027 PFS proposed rule, CMS-1848-P, published July 16, 2026 at 91 FR 43842, and it is not final.
Does the proposal change how modifier 25 is coded?
No. It changes payment, not coding. Modifier 25 still reports a significant, separately identifiable E/M, the level is still chosen on MDM or time, and the procedure is billed on its own line. The response is an exposure model and a contract review.
Which urgent care procedures are affected?
Any procedure with a 0-, 10- or 90-day global billed the same day as an office E/M by the same group: in urgent care, usually laceration repair, incision and drainage, splints, foreign body removal and lesion procedures. The global period is a code-level attribute; pull it from the PFS relative value file for your top twenty codes.
When will we know if it is final?
The CY2027 final rule is expected in the usual November window, effective January 1, 2027. CMS also asked whether 25 percent would be more appropriate than 50, so the final number may differ. Re-check every figure here against the final rule.
- CMS fact sheet, Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Rule (July 14, 2026)
- Federal Register, 91 FR 43842, CMS-1848-P, CY 2027 Payment Policies Under the Physician Fee Schedule, proposed rule (July 16, 2026), section II.B.(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods, pages 43907 to 43909
- American Medical Association, CPT Evaluation and Management (updated January 26, 2026)
- CMS Place of Service Code Set (page last modified February 17, 2026)
Checked October 25, 2026. Rules change; confirm against the source before relying on them. Figures from the CY2027 Physician Fee Schedule proposed rule are proposed, not final; re-check them against the final rule.
Want the exposure model run on your Medicare book before the final rule?
Send twelve months of 835s. We join them to the PFS global indicators and return the exposure at 50 and 25 percent, by procedure family and site.