Don't fix surgery's Medicare cut problem on primary care's back

In comments on the 2027 Medicare Physician Fee Schedule proposed rule, the American College of Surgeons (ACS) opposes Medicare’s plan to pay only 50% of a separately identifiable evaluation and management (E/M) visit billed with modifier 25 on the same day as a 0-, 10- or 90-day global procedure. The ACS then makes a specific proposal: If the Centers for Medicare & Medicaid Services (CMS) believes same-day services overlap, it should also examine “multiple cognitive services provided on the same day by the same provider.” The ACS names the Medicare Annual Wellness Visit (AWV) as the leading example. Under the proposed rule, a problem-oriented E/M visit billed with modifier 25 on the same day as an AWV would still be paid in full because the reduction applies only to E/M services billed with global procedures.

The ACS' companion analysis says the AWV (G0439) has "an outsized impact," appearing with an office visit nearly 5 million times in 2024 and accounting for approximately $630 million in allowed charges. It notes that only 37% of AWV claims are billed alone. It warns that for some providers, adding other E/M codes produces "encounter valuations greater than some surgical procedures that include 90 days of postoperative care." The ACS is careful to say this "is not, by itself, an argument that CMS should reduce payment for overlapping services." But the message is plain enough: If surgeons take a cut, primary care should share it.

The argument sounds balanced, but it is not. It treats a statutory preventive benefit and the chronic disease care delivered alongside it as if they were an operation, with the preoperative visit already built in. Those are different kinds of services, and the payment logic that fits one does not fit the other.

What the AWV actually pays for

The AWV is not a physical exam, and it is not a problem-oriented visit. The CMS' AWV requirements spell out the work:

• Health risk assessment covering psychosocial risks, behavioral risks, activities of daily living and instrumental activities of daily living
• Updated medical and family history
• List of current providers and suppliers
• Measurements
• Cognitive assessment
• Depression risk review
• Functional ability and safety review, including fall risk and hearing
• Written five- to 10-year screening schedule based on U.S. Preventive Services Task Force and Advisory Committee on Immunization Practices recommendations
• List of risk factors and conditions
• Personalized health advice and referrals
• Optional advance care planning
• Review of opioid prescriptions
• Substance use disorder screening

Nowhere in that list is treating hypertension, adjusting insulin, titrating heart failure medications, reconciling a specialist's new prescription with the rest of a medication list or working up a new symptom. None of that is part of the AWV. Coding guidance says the same: The AWV requirements "don't include treating a patient's chronic conditions, so it's best to bill each separately."

The CMS’ own AWV guidance says: "When you provide an AWV and a significant, separately identifiable, medically necessary [E/M] service, we may pay for the additional service. Report the additional [Current Procedural Terminology] code [99202-99205, 99211-99215] with modifier 25."

Why the surgical comparison fails

The CMS' same-day proposal assumes a global surgical package already pays for the preprocedure evaluation, so a same-day E/M visit pays twice for part of the work. The ACS disputes that with a detailed valuation history, and it may be right. But the theory does not carry over to the AWV, for three reasons.

First, there is no package. The AWV has no global period and no bundled E/M work. It does not pay for managing disease today, and it certainly doesn't pay for managing it over the next 90 days. When a primary care physician bills a 99214 alongside G0439, the E/M covers work the AWV explicitly leaves out.

Second, the services have different goals. A decision-for-surgery visit and the procedure are two steps toward one clinical goal. The AWV is a prevention and risk stratification that Congress required. The E/M is the treatment of active disease. And the AWV often uncovers new problems, such as a positive depression screen, a fall or cognitive decline. Those findings create clinical work; they don't duplicate it.

Third, the Medicare beneficiaries who come to an AWV are rarely healthy. They arrive with diabetes, chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, depression and a stack of recommendations from several specialists. Running through the AWV elements while ignoring a hemoglobin A1c of 9.4 or a blood pressure of 168/96 is not efficiency — it is bad medicine. Making the patient return another day to bill "cleanly" costs the beneficiary a trip and delays care.

The ‘94 Minutes’ problem

The ACS argues that billing G0439 with 99214 “would imply that physicians spent 94 minutes per patient,” plus “over 100 minutes of clinical staff time.” That figure adds up the Relative Value Scale Update Committee’s valuation assumptions. They do not describe what happens in the exam room. Time is also only one way to select an office E/M level. Since 2021, a 99214 can be billed on total time or on moderate medical decision-making, which reflects the number and complexity of problems addressed, the data reviewed and the risk of management. When the visit is billed on decision-making, there is no implied minute count to add to the AWV. The AWV itself was built to be done largely by staff and the patient. The CMS lets health educators, registered dietitians and other licensed professionals furnish parts of it under physician supervision, and the patient can complete or update the health risk assessment before the visit. That team-based design was deliberate. Stacking time assumptions from a team-delivered preventive service on top of a complexity-based problem visit is not evidence of inflated billing.

If the ACS wants to substitute observed activity for assumed time, that standard should apply everywhere. RAND's claims-based analysis for the CMS found that in 2019, 96.5% of procedures with 10-day global periods had no associated postoperative visit reported. Among 90-day global procedures, only 38% of expected postoperative visits were reported. A specialty whose packages pay for visits that often aren't documented as delivered should be cautious about citing primary care's assumed minutes as proof of overpayment.

This is primary care's benefit, and primary care's burden

The ACS' own analysis says what matters most: "AWVs are performed almost exclusively by family physicians, internists and advanced practice providers." That is the point. The AWV is primary care's work. Primary care closes the screening gaps, finds cognitive impairment early, starts advanced care planning and keeps track of every clinician involved. Primary care is then held accountable for that work through quality measures, accountable care organization (ACO) benchmarks and risk-adjusted outcomes.

The AWV is also where longitudinal care comes together. It is often the one visit each year when medications, specialist recommendations, discharges, care gaps and goals are reviewed together. The CMS already recognizes that this ongoing responsibility has real costs. That is why G2211 exists, and why the 2027 proposal would turn it into a 16% modifier, with a 32% version for clinicians in ACOs in the Medicare Shared Savings Program and Long-term Enhanced ACO Design model. Cutting the E/M billed with the AWV would take back from primary care the same dollars the CMS is trying to add.

Discouraging same-day chronic care management at the AWV would push practices toward either split visits that burden older patients or checkbox AWVs with no clinical follow-through. Neither serves Medicare's stated goal, which the 2027 rule describes as shifting "toward a focus on preventive rather than reactive medicine."

The compensation context that the ACS leaves out

The ACS frames its position around fairness: Apply "consistent principles across the [Physician Fee Schedule]." Fairness has to account for who is being paid what.

Primary care physicians are still among the lowest-paid in medicine. Every major compensation survey puts family medicine and internal medicine at or near the bottom, whereas surgeons and proceduralists sit at the top and often earn far more. Primary care is not where the fee schedule’s excess money is hiding.

Everyone is under pressure. The ACS notes that inflation-adjusted Medicare physician payment fell 33% from 2001 to 2025, and both proposed 2027 conversion factors fall below 2026 levels. Under budget neutrality, every dollar moved comes from someone. The profession should fight together for an inflation update that the ACS supports, not steer cuts toward the lowest-paid physicians doing the work.

The AWV pays approximately $138 nationally, with no patient cost-sharing. A 99214 pays approximately $136. Together they come to roughly $274 for a Medicare patient with several chronic conditions who gets prevention planning, cognitive and depression screening, fall-risk review, medication management and chronic disease care in one visit. Suggesting that this combination is richly paid compared with a surgical procedure that includes 90 days of care, much of which RAND found is often not reported, gets the comparison backward.

What the CMS should do

The CMS should reject the implied link between surgical same-day reductions and the AWV, specifically the following:

Keep preventive services out of any same-day payment reduction. The CMS already treats problem-oriented care delivered alongside a preventive visit as a separate, payable service.

Police modifier 25 through documentation, not percentage cuts. A significant, separately identifiable, medically necessary E/M should be paid; existing audit tools handle the rest.

Finish the work on primary care valuation. The 2027 proposed rule asks how to "reconsider relative primary care payment." Cutting the E/M visit billed with the AWV would undercut that effort before it begins.

Surgeons have a legitimate complaint about a 50% cut built on a theory that the CMS has now proposed three times without new evidence. But the right answer to a poorly supported cut is to defeat it, not to propose a matching cut for primary care. The AWV is required, preventive and performed almost entirely by primary care. The chronic disease care done at the same visit is separate work, done by the clinicians responsible for the patient over time, who earn far less than surgeons. Paying for both isn't paying twice; it's what longitudinal primary care costs. Only in Medicare could surgeons, paid for 90 days of visits that may never happen, accuse primary care of billing for work it actually did.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School and completed his residency at East Carolina University. He also holds an MBA from Duke University.