E/M & Modifier -25: The Most Significant Provision for Wound Care

What CMS proposed. CMS proposes that when a separately identifiable office/outpatient (O/O) E/M visit is billed with modifier -25 by the same physician (or a physician in the same group practice) on the same day as a 0-, 10-, or 90-day global procedure, only the most expensive service on the claim (procedure or visit) would be paid at 100%, and every other same-day service, including the E/M visit, would be paid at 50%. Separately, CMS proposes to delete HCPCS code G2211 (the E/M complexity add-on) and replace it with a two-digit modifier (“MOD1”) valued at 16% of the base E/M code’s total RVUs, applicable to office/outpatient and home-or-residence E/M visits. A second modifier (“MOD2”), paying 32% of the base E/M, would be available to practitioners in Medicare Shared Savings Program and LEAD Model ACOs. CMS also seeks comment on whether the 50% reduction should instead be 25%, and on whether the modifier -25 policy should extend to other E/M families such as inpatient visits.

Sources: CY2027 PFS proposed rule (CMS-1848-P), §II.D(58) and §II.D(53). See the full rule.

The modifier -25 payment reduction

Global surgical packages (the 0-, 10-, and 90-day global periods attached to most procedure codes) already include payment for the typical pre-operative, intra-operative, and post-operative visit work associated with the procedure. Because of that, a stand-alone E/M visit is only billable on the same day as a global procedure when it is “significant and separately identifiable,” flagged with modifier -25. CMS’s position in the CY2027 proposed rule is that even those separately identifiable visits likely duplicate resources already paid inside the global package, and that same-day services share efficiencies (one room, one check-in, one set of pre- and post-service work) that current payment does not capture.1

The proposed mechanism is modeled directly on the longstanding surgical multiple procedure payment reduction (MPPR): when an O/O E/M visit with modifier -25 is furnished on the same day as a 0-, 10-, or 90-day global procedure by the same physician or group, Medicare would rank every service on the claim, pay the single most expensive one at 100%, and pay all other procedures and the E/M visit at 50%.2 CMS’s own worked example, using CY2026 RVUs: a patient has a 99212 established-patient visit (1.78 total non-facility RVUs) plus two lesion shavings, 11300 (2.89 RVUs) and 11301 (3.48 RVUs). Code 11301 is the most expensive, so it is paid in full; 11300 falls to 1.445 RVUs and the 99212 falls to 0.89 RVUs.3

This revives a proposal CMS floated in CY2019 but never finalized; that version would have cut the least expensive of the visit or a 0-day global procedure by 50%.4 The CY2027 version is broader, sweeping in 10- and 90-day globals as well. Three things in the proposal are still open questions rather than firm policy: CMS seeks comment on whether the reduction should be 50% or a smaller value such as 25%5; on whether the policy should extend beyond O/O E/M to other visit families, such as inpatient E/M6; and on whether conditions of payment are needed to address payment-motivated scheduling (e.g., moving visits to a different day to avoid the reduction).7 CMS also issues a specific comment solicitation on intravitreal eye injections (CPT 67028)8 and asks more generally whether new-patient E/M work is already embedded in the valuation of minor procedures.9

As proposed, the reduction applies only to office/outpatient E/M codes.10 Nursing-facility E/M (99304-99310) and other visit families are not captured, though the extension solicitation means that boundary is explicitly open to comment.

What it hits in a wound visit

The classic wound-clinic encounter is exactly the claim this proposal targets: an established-patient office visit (9921x with modifier -25) for the medically necessary evaluation (vascular status, infection assessment, offloading, medication and comorbidity management) billed on the same day as the procedure that evaluation supports. Same-day surgical debridement (CPT 11042-11047) and skin-substitute application (CPT 15271-15278) are 0-day global procedures, so they sit squarely inside the proposed policy. Under the proposal, whenever the procedure prices higher than the visit (which is the usual case for debridement and virtually always the case for skin-substitute application), the E/M payment is cut in half, and any second same-day procedure is cut in half too.

The mechanics compound with the rest of the rule. Skin-substitute application is already facing its own payment restructuring (see Skin substitutes), and the E/M codes that anchor these visits already reflect the -2.5% work-RVU efficiency adjustment applied in CY2026, whose reduced work RVUs carry into CY2027 as the starting point, with no new adjustment until the next point in the three-year cycle.11 A wound practice’s same-day claim can therefore be touched from several directions at once; the combined arithmetic is worked through in Payment impact.

One boundary is notable: because the proposal is limited to office/outpatient E/M, nursing-facility visits are outside the reduction as proposed. A same-day NF E/M plus bedside debridement in a SNF would not trigger the reduction under the policy as written, but CMS’s open solicitation on extending the policy to other E/M families means that exemption is provisional rather than settled. See SNF & mobile wound care.

G2211 becomes MOD1 / MOD2

Since CY2024, practices have billed HCPCS G2211 as a separate add-on line to recognize the inherent complexity of visits where the practitioner is the continuing focal point of a patient’s care, or is managing ongoing care for a single serious or complex condition.12 In CY2026, CMS extended G2211 to the home-or-residence E/M family.13 For CY2027, CMS proposes to delete G2211 entirely and replace it with a modifier appended to the E/M line itself (placeholder “MOD1,” to become a two-digit HCPCS modifier if finalized), billable under the same circumstances G2211 is billed today.14

The valuation logic changes fundamentally. G2211 pays a flat 0.52 total non-facility RVUs regardless of visit level, which CMS notes boosts a 99212 by 29% but a 99215 by only 9%.15 MOD1 would instead pay 16% of the base E/M code’s total RVUs, making the complexity payment proportional across visit levels.16 CMS set the 16% using a weighted average of G2211’s percentage impact across the O/O E/M codes, weighted by utilization and adjusted to be budget-neutral. The practical effect: the add-on shrinks for low-level visits and grows for high-level ones.

MOD2 is the new element: a parallel modifier paying 32% of the base E/M’s total RVUs (double MOD1), available exclusively to ACO participants, professionals, and providers/suppliers in the Medicare Shared Savings Program and to LEAD Model Participant Providers, when the visit-complexity criteria are met.17 CMS proposes that ACO practitioners may bill MOD2 for any beneficiary they treat, not just those aligned to their ACO, and that use of either modifier is voluntary.18

MOD1 MOD2
Replaces HCPCS G2211 (flat 0.52 RVU add-on) New; no current equivalent
Payment 16% of base E/M total RVUs 32% of base E/M total RVUs
Who can bill Any practitioner meeting the longitudinal-complexity criteria Shared Savings Program / LEAD ACO practitioners only
E/M families Office/outpatient + home or residence (99341-99350) Same
Nursing-facility E/M (99304-99310) Not covered Not covered

The modifier -25 interaction bears directly on wound care claims. CMS proposes to carry forward the CY2025 limitation: MOD1/MOD2 would be payable on a -25 claim only when the E/M accompanies a same-day annual wellness visit, vaccine administration, or Part B preventive service.19 But CMS explicitly seeks comment on whether to also allow MOD1 or MOD2 when the O/O E/M is furnished on the same day as a 0-, 10-, or 90-day global procedure: precisely the wound-care scenario.20 That question is a solicitation, not a proposal; as drafted, a typical wound visit billed -25 alongside a debridement gets neither modifier.

Significance for wound care

For an office-based or hospital-outpatient wound practice, this is the most significant item in the rule. Chronic wound care is built on the same-day model: the patient with a diabetic foot ulcer or venous leg ulcer is evaluated and treated in one encounter because their mobility, transportation, and wound status make split visits impractical and clinically worse. Under the proposal, the cognitive half of that encounter (the E/M that determines whether debridement is safe, whether infection needs escalation, whether the vascular supply supports healing) is paid at half price on virtually every procedure day. Practices whose visit volume is dominated by E/M-plus-procedure days face a direct, recurring cut to a large share of their claims, layered on top of the skin-substitute restructuring and the carried-forward efficiency adjustment. And because the G2211-to-MOD1 conversion keeps the -25 restriction (pending the comment solicitation), the complexity payment that might have partially offset the cut is unavailable on exactly those days. The counterincentive CMS flagged in 2019 (bringing patients back on a different day to preserve full payment) is most relevant for a population that tolerates extra travel poorly.

Deep-dive: implications by practice model

Office-based wound practices have the heaviest exposure in the rule. Their revenue model concentrates on non-facility claims where an O/O E/M with modifier -25 accompanies same-day debridement (11042-11047) or skin-substitute application (15271-15278), 0-day global procedures that sit at the center of the proposed policy. On those claims, the procedure typically carries the higher total RVUs, so the E/M takes the 50% reduction; when two procedures are performed (for example, debridement of two sites at different depths, or debridement plus application), the second procedure is also halved under the MPPR-style ranking. The MOD1 conversion cuts both ways: proportional valuation raises the complexity payment on level 4-5 visits relative to today’s flat G2211, but as proposed MOD1 remains unbillable with -25 on global-procedure days, which for a wound practice is most procedure days. Non-ACO practices have no path to MOD2.

The double-counting premise fits chronic wound care imperfectly. The E/M embedded in a 0-day global reflects the minimal same-day evaluation typical of the procedure itself, while the modifier -25 visit in chronic wound care is often a distinct service (comorbidity management, vascular decision-making, escalation judgment) that occurs whether or not a procedure happens that day. To the extent that work is genuinely separate, a uniform 50% reduction discounts it as if it were duplicative. The final percentage is also unsettled: CMS explicitly raised 25% as an alternative, so the magnitude of the cut could change between proposal and final rule. The payment impact page walks through the claim-level arithmetic.

Mobile and traveling providers deliver wound care wherever the patient lives, from private homes to skilled nursing facilities, but the two settings diverge sharply on the E/M rules: home-or-residence E/M is eligible for the new MOD1 complexity modifier, while nursing-facility E/M is outside the -25 reduction yet excluded from MOD1 entirely.

For mobile practices billing home-or-residence E/M (99341-99350), one change in this rule is positive: the MOD1 proposal covers the home/residence family, so proportional complexity payments attach to house-call visits, and mobile practitioners affiliated with a Shared Savings Program or LEAD ACO could bill MOD2 at 32%. Exposure to the modifier -25 reduction depends on billing pattern. The reduction as proposed is triggered by an O/O E/M with -25 on the same day as a global procedure; because CMS drafted the reduction around office/outpatient visits specifically, its application to a home-visit E/M billed alongside bedside debridement is not explicitly addressed in the proposal text. Mobile practices that also run office days with same-day procedures carry the same exposure as any office practice on those days. See SNF & mobile wound care for the fuller mobile picture.

Relative to the other practice models discussed here, home-based mobile care faces less new downside in this section: MOD1 eligibility extends to home/residence E/M, where flat G2211 previously applied, and MOD2’s 32% rate changes the economics of ACO affiliation for mobile groups relative to the flat add-on. One drafting question remains open: the -25 reduction is written around office/outpatient E/M, and the proposal does not state whether that framing is a deliberate scope limit or shorthand, so the treatment of a home-visit E/M billed -25 with a same-day bedside procedure is not fully resolved by the proposal text.

SNF-based wound practitioners are, as proposed, outside the scope of the reduction: the modifier -25 reduction applies only to office/outpatient E/M, so nursing-facility visits (99304-99310) billed with same-day bedside debridement are not reduced. Two qualifications apply. First, CMS is expressly seeking comment on extending the policy to other E/M families; the same solicitation that names inpatient E/M could reach NF codes in a final rule or future rulemaking, so the exemption is a live question, not a settled one. Second, the MOD1/MOD2 proposal covers office/outpatient and home-or-residence E/M but not the nursing-facility family, so SNF practitioners get no complexity payment at all, continuing G2211’s exclusion of NF codes into the new structure. The SNF & mobile page covers the rest of the rule’s SNF-relevant provisions.

The SNF exemption is conditional rather than structural. The extension solicitation means nursing-facility exposure remains an open question: a policy finalized narrowly can be broadened in a later rule once the framework exists, and CMS has asked for exactly the input that would support doing so. If the reduction were extended, it would fall on the highest-acuity, least-mobile population in outpatient wound care, the group for whom returning on a separate day is least feasible. There is also an asymmetry in the complexity-modifier design: MOD1’s longitudinal-complexity rationale (an ongoing focal-point relationship) describes NF wound care as readily as office or home care, yet the NF family is excluded from both modifiers, carrying G2211’s exclusion forward without a stated rationale specific to the new structure.

Hospital-based outpatient wound centers see the professional-fee side of this proposal directly: physicians billing O/O E/M with -25 alongside same-day procedures at the center face the same 100%/50% ranking as office practices, applied to facility-rate RVUs. Because the facility-setting E/M carries lower total RVUs than its non-facility counterpart, the visit is even more reliably the cheaper service on the claim and thus the one reduced. Wound centers also concentrate skin-substitute application volume, so the interaction with the skin-substitute payment restructuring (see Skin substitutes) is most acute here. Center-affiliated physicians in health-system ACOs would be eligible for MOD2, but the -25 limitation means neither modifier attaches on procedure days as proposed.

The main second-order effect for wound centers is scheduling pressure. The economics the proposal creates (full payment for procedure-only days, halved E/M on combined days) push toward decoupling evaluation visits from procedure visits. CMS states that it considers payment-motivated scheduling “highly problematic” and lists monitoring tools; the incentive itself arises from the proposed payment differential. For a wound-center population with high amputation risk, split visits carry clinical costs: added delay to treatment, travel burden, and missed-appointment risk. How strongly that incentive operates in practice would depend on the final reduction percentage and on whether single-procedure days are ultimately exempted.

Considerations for providers and manufacturers

Each point below states what CMS proposed and then what it would mean in practice. These are analytical implications, not recommendations; some stakeholders may also weigh them when deciding whether to submit input during the public comment period.

  • The 50% cut rests on a “duplicate work” premise that fits chronic wound care imperfectly. CMS justifies halving the same-day E/M on the theory that its work is already embedded in the procedure’s global package. In chronic wound care the same-day evaluation (deciding whether debridement is safe, whether infection is escalating, whether perfusion supports healing) is distinct cognitive work. Because the reduction would apply on essentially every procedure day, the recurring revenue at stake for a wound clinic is the E/M portion of nearly all its same-day visits, and whether that work is duplicative is the central question underlying the policy’s premise.

  • 25% versus 50% is a multi-percent swing in total revenue. CMS explicitly floated 25% as an alternative. The difference is linear (a 25% reduction leaves three-quarters of the E/M versus half), so across a high-volume same-day book the choice between the two values moves total practice revenue by percentage points. CMS also asked whether to exempt the E/M when only one procedure is performed, which would leave the most common wound pattern (one debridement plus one E/M) unaffected.

  • Extending the cut beyond office E/M would remove the current SNF exemption. As drafted the reduction touches only office/outpatient E/M, which is why the mobile/SNF model is currently less exposed (see SNF & Mobile). CMS solicited comment on extending it to other families, such as inpatient (and by implication nursing-facility). If that happens, a nursing-facility E/M (e.g., 99308) plus a same-day bedside debridement would see the E/M halved just like an office visit, reversing the current relative advantage. The patients affected (nursing-facility and homebound) are also the least able to return on a separate day, so the split-visit alternative is least available in the settings an extension would newly cover.

  • The complexity add-on and the -25 cut can compound on the same claim. CMS asks whether MOD1/MOD2 (16%/32% of the E/M) may be paid when an office/outpatient E/M accompanies a 0-/10-/90-day global procedure. For longitudinal wound care the procedure day frequently is the longitudinal visit, so if the modifiers are barred there, the practices managing the most complex chronic patients lose the complexity payment on exactly the encounters it was built for, while the -25 policy simultaneously halves the base E/M. A barred add-on and a halved base would compound on the same claim rather than acting as two separate reductions.

  • Two unresolved boundaries leave the model’s economics unsettled. The proposal does not clearly state whether home-or-residence E/M (99341–99350) falls inside the -25 reduction, nor whether excluding nursing-facility codes from MOD1 is deliberate. Mobile wound care leans on home/residence E/M, so the first question decides whether the mobile model shares the office model’s exposure; if the NF exclusion from MOD1 is intentional, SNF-based practices are structurally shut out of the complexity payment despite comparable visit complexity. Until CMS clarifies, neither practice model’s CY2027 economics can be fully projected.

  • The policy creates a financial incentive to split same-day visits. Because same-day billing is reduced but separate-day billing is not, the design creates a financial reason to move the evaluation and the procedure to two visits. For a diabetic-foot or venous-ulcer patient with limited mobility, a second trip carries access and adherence costs, so the payment-maximizing path (split) and the clinically preferred path (same-day) diverge. How CMS treats medically rational same-day care (legitimate choice versus audit flag) would determine how that tension resolves.

The public comment period is open through September 14, 2026 (docket CMS-2026-2377). See How to Comment for the mechanics.

Footnotes

  1. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43908). CMS states:
    “This proposal is meant to address the likely overlap and duplication of payment between the E/M services already paid for during the global surgical package, and any additional E/M services billed for through the use of modifier-25 as significant and separately identifiable.” […] “As we stated in the CY 2019 final rule (83 FR 59638 through 59640), we continue to believe that there are efficiencies when the same physician (or a physician in the same group practice) provides an E/M service for the same patient in conjunction with a procedure with a global period, and that we are likely duplicating payment under the current payment methodology.”↩︎

  2. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43908). CMS states:
    “We are proposing to reduce payment, as described later in this section, when a separately identifiable O/O E/M visit is furnished by the same physician (or a physician in the same group practice) on the same day as a 0-, 10-, and 90-day global procedure. Under this proposal, the most expensive service (either surgical or E/M visit) would be paid at 100 percent, and all other surgical procedure(s) or E/M visit(s) would be paid at 50 percent.”↩︎

  3. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43908). CMS states:
    “Using 2026 RVU values, the total non-facility (NF) RVU of CPT code 99212 is 1.78, the total NF RVU of CPT code 11300 is 2.89, and the total NF RVU of CPT code 11301 is 3.48. Since CPT code 11301 is the highest paid service, CPT code 11301 will be paid at 100 percent (total RVU of 3.48), and CPT code 11300 and the payment for CPT code 99212 will both be reduced by 50 percent, CPT code 11300 down to 1.445 RVUs and CPT code 99212 down to 0.89 RVUs.”↩︎

  4. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43908). CMS states:
    “In the 2019 PFS proposed rule (83 FR 35840 through 35841), as part of a suite of proposals designed to modify the payment structure of E/M visits, we proposed to reduce payment by 50 percent for the least expensive 0-day global procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier-25.”↩︎

  5. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43908). CMS states:
    “The 50 percent value aligns with our previous proposal from CY 2019 PFS proposed rule (83 FR 35840 through 35841) and matches the longstanding surgical MPPR discussed previously in this section. We welcome comments on the value of this adjustment, including whether it would be more appropriate to match a different MPPR value, such as 25 percent.”↩︎

  6. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43909). CMS states:
    “While we are proposing to apply this policy only to O/O E/M visits, we are seeking comments on whether it should also apply to other E/M visits, such as inpatient E/M visits.”↩︎

  7. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43909). CMS states:
    “We reiterate that we do not find it appropriate to schedule medical services for patients to maximize payment, which would create undue burden and potential medical risk for beneficiaries.” […] “We are also seeking comment on whether or not it is necessary to revise the conditions of payment to mitigate such payment abuses.”↩︎

  8. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43909). CMS states:
    “We are also seeking comment on how this policy might apply to an E/M visit reported on the same day as intravitreal eye injection, such as CPT code 67028, a high volume 000-day global code.”↩︎

  9. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43909). CMS states:
    “We are also seeking to better understand whether the E/M work associated with new patients is typically included in valuation of the minor procedures, or whether there is extra work for new patients that is significant and separately identifiable enough to always warrant separate payment.”↩︎

  10. Proposed rule §II.D(58), Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods (CMS-1848-P, 91 FR 43909). CMS states:
    “While we are proposing to apply this policy only to O/O E/M visits, we are seeking comments on whether it should also apply to other E/M visits, such as inpatient E/M visits.”↩︎

  11. Proposed rule §II.D(2)(b), Efficiency Adjustment (CMS-1848-P, 91 FR 43868). CMS states:
    “In the CY 2026 final rule, we finalized the establishment of an efficiency adjustment to the work RVUs, as well as corresponding updates to the intraservice portion of physician time inputs for non-time-based services, with refinements (90 FR 49334 through 49345). We finalized a policy to apply this efficiency adjustment to the intraservice portion of physician time and work RVUs every 3 years.” […] “Therefore, we finalized the proposed efficiency adjustment of 2.5 percent.”↩︎

  12. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43899). CMS states:
    “We discussed in the CY 2024 final rule (88 FR 78973) that HCPCS code G2211 was intended to characterize the associated E/M code as a service with a practitioner who serves as the continuing focal point for all needed health care services, or with medical care that is part of ongoing care related to a patient’s single, serious, or complex condition. HCPCS code G2211 was meant to describe the inherent complexity of these visits that would otherwise be unaccounted for.”↩︎

  13. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43898). CMS states:
    “In the CY 2026 PFS final rule (90 FR 49462 through 49464), we finalized our proposal to allow HCPCS code G2211 to be billed as an add-on code with the home or residence E/M visits code family (CPT codes 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350).”↩︎

  14. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43899). CMS states:
    “We are therefore proposing to replace HCPCS code G2211 with a modifier, which we will refer to in this proposed rule as MOD1, which is a placeholder that would be replaced with a two-digit HCPCS modifier, if finalized. We are proposing that modifier MOD1 will be billed under the same circumstances that HCPCS code G2211 is billed now.”↩︎

  15. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43899). CMS states:
    “For example, HCPCS code G2211 has a total RVU of 0.52 in the non-facility (NF) setting. CPT code 99212 […] has a total NF RVU of 1.78. So, when HCPCS code G2211 is appended to CPT code 99212, the overall value of the service is increased by 29 percent. However, when HCPCS code G2211 is appended to CPT code 99215 […] with a NF total RVU of 5.76, it only represents a 9 percent increase in the total value of the service.”↩︎

  16. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43899). CMS states:
    “We believe that HCPCS code G2211 should reflect an increase to the base code that is proportional across all types of E/M visits. Therefore, we are proposing a modifier to replace HCPCS code G2211 with the valuation of 16 percent of the base E/M code. We established this percentage using a weighted average of the percentage increase that G2211 comprised relative to the O/O E/M code, weighted by HCPCS code G2211 utilization and adjusted to achieve budget neutrality.”↩︎

  17. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43901). CMS states:
    “With these goals in mind, we are proposing that, in place of reporting G2211, ACOs would have the option to report a modifier on a claim (referred to in this proposed rule as placeholder MOD2, which if finalized would be replaced with a two-digit HCPCS modifier), which will be valued at 32 percent of the associated E/M visit when performed by Shared Savings Program ACO participants, ACO professionals, and ACO providers/suppliers (as each is defined at § 425.20), as well as Participant Providers in the LEAD Model. We are proposing that MOD2 would pay twice the rate of MOD1 to better account for the inherent complexity of some visits in the ACO context, specifically applying to Shared Savings Program and LEAD ACOs in situations that require increased time and intensity.”↩︎

  18. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43901). CMS states:
    “We are further proposing that the use of this modifier be voluntary; and ACO participants, ACO professionals, ACO providers/suppliers (as each is defined at § 425.20, for the Shared Savings Program), and LEAD Participant Providers would determine if this modifier is necessary based on visit complexity and would append MOD1, MOD2, or no modifier, as appropriate. Additionally, we are proposing that ACO participants, ACO professionals, and ACO provider/suppliers (as each is defined at § 425.20, for the Shared Savings Program), as well as LEAD Participant Providers may bill this modifier for all beneficiaries to whom they provide care, regardless of whether that beneficiary is assigned, aligned, or attributed to an ACO, to encourage similar care to be provided to all beneficiaries served by health care providers who participate in ACOs.”↩︎

  19. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43902). CMS states:
    “We finalized HCPCS code G2211 as payable in the CY 2024 PFS final rule (88 FR 78974), and in the CY 2025 PFS final rule (89 FR 97856 through 97858), we finalized that we would allow payment of HCPCS code G2211 with -Modifier 25 when the O/O E/M base code is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventative service when furnished in the office or outpatient setting. For CY 2027, we are proposing to maintain the same limitations we established for HCPCS code G2211 in the CY 2025 PFS final rule (89 FR 97856 through 97858) for MOD1 and MOD2 when billed with Modifier -25.”↩︎

  20. Proposed rule §II.D(53), Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211) (CMS-1848-P, 91 FR 43903). CMS states:
    “Later in this section, we are making additional proposals related to changes for payment when modifier -25 is appended. Given these changes, we are seeking comment on whether we should consider changes to this policy, such as allowing MOD1 or MOD2 to be billed with modifier -25 when an O/O E/M is performed on the same day as a 0-, 10-, or 90- day global procedure?”↩︎