Two weeks ago we summarized the CY 2027 physician fee schedule proposed rule, released July 14, 2026. Two of its proposals generated more questions from the practices we work with than everything else combined, so this article does the arithmetic. The numbers below use approximate 2026 national non-facility payment amounts, rounded, and they are illustrations, not a fee schedule. Your locality and your actual code mix will move them. The comment deadline is September 14, 2026, and these are exactly the kinds of numbers CMS asks commenters to provide.
One caution before the tables. Both proposals interact with the conversion factor cut to $32.84, so a practice modeling 2027 should apply the percentages to proposed 2027 rates, not to this year's. We have used 2026 figures here because they are the ones you can check against your own remittances.
Key takeaways
- As a 16 percent modifier, G2211 pays more than the flat add-on on 99214 and 99215 and less on 99212 and 99213. The break-even sits at about 99214.
- The 32 percent modifier for Shared Savings Program and LEAD Model participants is worth roughly $40 on a 99214, for every patient, not only attributed ones.
- The same-day E/M proposal halves whichever service is lower valued on the claim. For dermatology and ENT that is usually the visit; for podiatry and primary care it is often the procedure.
- Your exposure is two exports and a spreadsheet. Do it before September 14 and put the result in a comment.
Proposal one: G2211 becomes a 16 percent modifier
Since January 2024, G2211 has been a flat add-on, paid at roughly $16 to $17 nationally, reported with office and outpatient E/M visits when the practitioner is the continuing focal point for the patient's care or is managing a single serious or complex condition over time. CMS proposes to delete the code and replace the flat amount with a modifier that raises the underlying E/M payment by 16 percent. A second modifier for clinicians in Shared Savings Program ACOs and the LEAD Model would raise it by 32 percent, for all of their Medicare patients.
The effect depends entirely on which visit level carries the add-on:
| E/M code | Approximate 2026 payment | Flat G2211 (about $16.50) | 16 percent modifier | Difference per visit |
|---|---|---|---|---|
| 99212 | $58 | $16.50 | $9.30 | -$7.20 |
| 99213 | $92 | $16.50 | $14.70 | -$1.80 |
| 99214 | $130 | $16.50 | $20.80 | +$4.30 |
| 99215 | $183 | $16.50 | $29.30 | +$12.80 |
The break-even sits around 99214. A primary care practice whose G2211 visits are mostly 99214 and 99215, which is what the code was designed for, comes out ahead. A practice that has been attaching G2211 to 99212 and 99213 visits loses on each one, and honestly, some of those claims should not have carried the code in the first place. In audits we regularly find G2211 on acute, single-problem 99213 visits with no longitudinal relationship documented; the modifier proposal quietly reduces the reward for that pattern.
Worked example: a two-physician internal medicine practice bills 6,000 G2211 claims a year to Medicare, split 10 percent 99212, 30 percent 99213, 50 percent 99214, 10 percent 99215. Using the table, the annual change is roughly (600 × -7.20) + (1,800 × -1.80) + (3,000 × 4.30) + (600 × 12.80), which comes to about +$13,000. The same practice with a 40/40/20/0 split comes out at about -$14,000. Same code, opposite result.
For ACO participants the 32 percent modifier is a substantial number: about $41.60 on a 99214, on every Medicare beneficiary. A practice with 4,000 qualifying 99214 visits a year would see roughly $100,000 more than under the flat add-on. If you have been on the fence about Shared Savings Program participation, this proposal is designed to push you, and the rule's increase in the BASIC track Level E sharing rate from 50 to 60 percent is the other half of the push.
One more wrinkle. As a modifier, the add-on would rise and fall with the conversion factor and with any future revaluation of the E/M codes themselves, where the flat G2211 amount moved only with its own relative value. Practices modeling 2027 should apply the 16 percent to the proposed 2027 E/M rates and should assume that Medicare Advantage plans paying a percentage of the fee schedule will follow whatever CMS finalizes in November.
Proposal two: same-day E/M with a global procedure paid at 50 percent
Today, when a physician performs a minor procedure with a 0- or 10-day global period and also performs a significant, separately identifiable E/M service on the same day, the E/M is billed with modifier 25 and paid in full, provided the documentation supports it. CMS proposes that when an E/M is billed with a same-day 0-, 10- or 90-day global procedure by the same physician or a physician in the same practice, the highest-valued service is paid at 100 percent and every other service on the claim, including the E/M, at 50 percent. CMS names dermatology, otolaryngology and podiatry as the specialties most affected, and asks whether a 25 percent reduction would be more accurate.
| Scenario | Codes | Approximate payments | Service paid at 50 percent | Loss per encounter |
|---|---|---|---|---|
| Dermatology: follow-up visit plus tangential biopsy | 99213-25 + 11102 | $92 + $105 | The 99213 | about $46 |
| Podiatry: diabetic visit plus nail debridement | 99213-25 + 11721 | $92 + $46 | The 11721 | about $23 |
| ENT: sinus visit plus nasal endoscopy | 99214-25 + 31231 | $130 + $205 | The 99214 | about $65 |
| Primary care: visit plus joint injection | 99214-25 + 20610 | $130 + $70 | The 20610 | about $35 |
| Orthopedics: new patient visit plus fracture care | 99203-25 + 26600 | $115 + $290 | The 99203 | about $57 |
A dermatology practice with three physicians who each see eight biopsy-plus-visit encounters a day, four days a week, has roughly 4,600 such encounters a year. At about $46 each that is around $210,000 of Medicare revenue, before Medicare Advantage plans that pay a percentage of the fee schedule follow the policy, and before commercial payers decide to adopt it, which several will. At the 25 percent alternative CMS floats, the same practice loses about $105,000. Neither number is small for a three-physician group.
Our view
We think the G2211 proposal is defensible and the same-day proposal is not. Multiple procedure reduction exists because the second procedure shares pre- and post-service work with the first. A separately identifiable E/M visit, by definition, does not share that work; if it did, modifier 25 would not apply. Paying it at half is a payment cut dressed as a valuation principle. Practices should say so in comments, with their own numbers, and should answer CMS's question about 25 percent directly: if the answer is that no reduction is justified where documentation supports the visit, say that.
How to model your own exposure
- Export twelve months of Medicare claims with G2211. Count by E/M level. Multiply by the per-visit differences above, adjusted for your locality.
- Export twelve months of claims where an E/M with modifier 25 appears on the same date as a code with a 0-, 10- or 90-day global indicator. The indicator is in the fee schedule relative value file; your billing system may already store it. For each, identify the higher-paid service and halve the other.
- Add the two results. That is your CY 2027 exposure from these two proposals alone, before the conversion factor cut.
- Repeat step two at 25 percent so you can answer CMS's alternative question with a number.
- Write the numbers into a comment. CMS reads specific dollar impacts from specific specialties; it does not read "this will hurt patients" as data.
What the export usually shows
When we run these two exports for practices, a few patterns repeat. G2211 is often attached to a smaller share of eligible visits than the practice assumes, because some providers never adopted it; the modifier proposal is a reason to fix that regardless of level. Modifier 25 encounters cluster around a handful of procedures per specialty, usually three to five codes, which makes the comment letter easy to write and makes the scheduling conversation, if it comes to that, specific. And a surprising number of same-day encounters are billed without modifier 25 at all, meaning the E/M was denied as bundled and never appealed. That last finding is money you are already losing under current rules, and it does not need a final rule to fix.
Questions we hear
Should we stop billing G2211 on 99213 visits now?
Bill it when the documentation supports the longitudinal relationship, regardless of level. Do not bill it because it pays. That was the rule before this proposal and it will be the rule after. What you should do now is audit twenty G2211 claims at 99213 and see whether the relationship is documented; if it is not, you have a compliance problem that predates the rule.
Could we split the procedure and the visit across two days?
Scheduling a medically unnecessary second visit to avoid a payment reduction is the kind of behavior that draws audits, and it costs the patient a trip. If the proposal is finalized, some practices will schedule differently for legitimate clinical reasons, such as a procedure that needs a consent conversation and a return visit anyway; that is different, and the note should show why.
Can you run this analysis for us?
Yes. Practices on our medical billing service will see both numbers in their August report. Others can request it as part of an RCM audit, which includes the modifier 25 documentation review alongside the dollar model.
What to do this month
- Run the two exports described above and total your exposure at 50 percent and at 25 percent.
- Audit twenty G2211 claims at 99213 for a documented longitudinal relationship.
- Pull same-day encounters billed without modifier 25 and appeal the bundled E/M denials that are still within the timely filing window.
- Draft a one-page comment with your specialty, your counts and your dollar figures, and hold it for the September 14 deadline.
- If you are in an ACO or considering one, model the 32 percent modifier against your 99214 and 99215 volume before the fall application cycle.
