CMS Proposes 50% Payment Cut on Same-Day Urology E/M Visits Billed With Modifier 25

QUICK ANSWER

• What is the 2027 modifier 25 payment reduction for urology? As of July 2026, the CMS CY 2027 Physician Fee Schedule proposed rule (CMS-1848-P) includes a provision that would reduce Medicare payment by 50% on any evaluation and management visit billed with modifier 25 on the same day as a procedure carrying a 0-day, 10-day, or 90-day global period. The highest-paid service on the claim would be reimbursed at 100%, while every additional service that day would drop to half. For urology practices, where same-day cystoscopy plus office visit billing is routine, this proposal could cut per-encounter revenue by $50 to $100 or more if finalized and effective January 1, 2027.
• 50% reduction on the lesser service: Whether the E/M visit or the procedure pays less, CMS would reimburse the lower-valued service at half the fee schedule rate.
• Applies across all global periods: Unlike the narrower 2019 proposal that targeted only 0-day globals, this version covers 0-day, 10-day, and 90-day global procedures.
• Comment period closes September 14, 2026: The rule is proposed, not finalized, and CMS could narrow, delay, or withdraw the provision in the final rule expected November 2026.

What CMS Proposed on July 14

CMS released the CY 2027 Physician Fee Schedule proposed rule (CMS-1848-P) on July 14, 2026. Among the dozens of provisions in the 1,592-page document, the modifier 25 payment reduction stands out as one of the most operationally disruptive for procedural specialties, and urology is named explicitly as one of the specialties carrying the heaviest same-day billing volume.

The proposal works like this. When a physician or a physician in the same group practice furnishes a separately identifiable E/M visit on the same day as a procedure with a 0-day, 10-day, or 90-day global period, CMS would pay the highest-valued service at 100% of the fee schedule amount and reduce every additional service on that date to 50%. The modifier 25 designation on the E/M claim would no longer guarantee full separate payment. CMS argues that clinical efficiencies are achieved when both services happen in the same encounter and that the current payment methodology results in duplicate reimbursement for overlapping work.

This is not the first time CMS has attempted this cut. In the CY 2019 PFS proposed rule, the agency proposed a narrower version that would have reduced only the lesser 0-day global procedure by 50% when billed with a separate E/M. After pushback from specialty societies and commenters, CMS did not finalize the 2019 version. The 2027 proposal is broader. It covers all global period lengths and reduces the lesser service regardless of whether it is the procedure or the E/M. The 60-day public comment period closes September 14, 2026, and the final rule is expected by November 2026.

Does the Modifier 25 Cut Apply to My Urology Practice?

If your urology practice bills Medicare for any office visit on the same day as a procedure, the answer is yes. The provision applies to every same-day combination of an E/M visit and a procedure carrying a global period, and urology has one of the highest concentrations of these pairings of any specialty.

The most common urology scenario is a diagnostic cystoscopy billed under CPT 52000 performed on the same day as an office E/M visit. CPT 52000 carries a 0-day global period. Under current rules, the practice bills the cystoscopy at 100% and the E/M visit at 100% with modifier 25, provided the note supports a significant, separately identifiable service. Under the proposed rule, the lesser of the two services would be paid at 50%. For a non-facility setting where 52000 pays approximately $216 and a 99213 pays approximately $106 under the 2026 fee schedule, the practice would lose roughly $53 on that single encounter.

The impact is not limited to cystoscopy. Urodynamic studies, prostate biopsies under the new 55707 through 55715 code family, in-office lithotripsy, and bladder instillation procedures all carry global periods and are frequently paired with same-day E/M visits. Practices performing a high volume of in-office procedures stand to lose the most because the cut compounds across every qualifying encounter.

Across the billing companies we vet for urology practices, the modifier 25 pair of cystoscopy plus E/M is the single most common same-day billing pattern we see. Practices that do not model the revenue impact of this proposal before the comment deadline risk being caught unprepared if the provision is finalized.

Why CMS Is Targeting Same-Day Billing

CMS frames the modifier 25 reduction as a correction for overpayment. The agency’s rationale, laid out in the proposed rule, centers on what it calls shared efficiencies. When a physician sees a patient for an E/M visit and performs a procedure during the same encounter, CMS argues that certain resources and work overlap between the two services. The history and physical exam that supports the E/M visit, for example, also informs the procedural decision-making. Staff intake, room setup, and documentation time may serve both services simultaneously. CMS believes the current payment methodology pays for these shared elements twice.

The agency compares the proposal to the existing multiple procedure payment reduction (MPPR) already applied to therapy services and diagnostic imaging, where the second and subsequent services performed in the same session receive reduced practice expense payments. CMS argues the same logic applies when an E/M visit is furnished alongside a procedure.

Specialty societies, including the AUA and the AMA, have historically pushed back on this reasoning. The counterargument is that modifier 25 exists precisely to identify a separately identifiable service, meaning the E/M visit addressed a clinical issue that went beyond the pre-service and post-service work already built into the procedure’s global period. If the documentation supports a distinct service, the payment is not duplicative. The AUA’s summary of the proposed rule notes that the modifier 25 provision is one of several policies contributing to a projected negative 2% net impact on total Medicare charges for urology in 2027.

How Much Revenue Could a Urology Practice Lose?

The dollar impact depends on how many same-day E/M-plus-procedure encounters the practice bills in a typical month. The table below models the per-encounter reduction for four common urology code pairs using 2026 Medicare non-facility rates, since 2027 final rates have not been published.

These estimates use approximate 2026 Medicare Physician Fee Schedule non-facility rates. Actual 2027 rates will differ based on the final conversion factor and any changes CMS makes in the final rule. The reduction applies only when both services are furnished by the same physician or a physician in the same group practice on the same date.

For a practice performing 80 same-day cystoscopy-plus-E/M encounters per month, a $53 per-encounter loss translates to roughly $4,240 per month, or just over $50,000 annually from that single code pair. Practices with a heavier procedure mix or higher E/M levels would see a proportionally larger impact. In our experience matching providers with billing partners, the practices most exposed are mid-size groups performing a high volume of in-office procedures where same-day E/M billing is standard workflow, not an exception.

What to Do Before the Comment Period Closes

The comment period for CMS-1848-P closes September 14, 2026. Whether or not the provision is finalized, these steps protect the practice regardless of the outcome.

1. Pull a modifier 25 utilization report. Run a report for the last 12 months showing every claim where modifier 25 was appended to an E/M visit alongside a procedure with a global period. Sort by CPT code pair and calculate the total reimbursement currently received on the reduced service.
2. Model the revenue impact per code pair. For each code pair, calculate 50% of the lesser service’s allowed amount and multiply by annual volume. This gives the projected annual revenue loss if the rule is finalized as proposed.
3. Review documentation supporting modifier 25 use. Even if the payment reduction is finalized, documentation quality determines whether claims survive audits. Confirm that every modifier 25 E/M note documents a separately identifiable service that goes beyond the pre-service and post-service work of the procedure.
4. Evaluate scheduling workflow. If the cut is finalized, some practices may choose to separate the E/M visit and the procedure into different dates of service where clinically appropriate. This is a scheduling decision, not a billing workaround, and it must be driven by patient care needs.
5. Submit a public comment to CMS. The AUA and AMA are expected to comment against the provision. Individual practice comments citing specific revenue impact data strengthen the case. Comments are accepted electronically through regulations.gov under docket CMS-1848-P.
6. Confirm your billing company is tracking the rule. If your billing partner has not flagged this provision or modeled its impact, that is a signal worth paying attention to. The practices that adjust before a rule takes effect collect more than those that react after the first denied or reduced claim.

Common Misreadings of This Proposal

The proposed rule has generated significant discussion, and several misreadings are circulating. Getting the details right matters, because the difference between the actual proposal and what some summaries describe changes the revenue math and the strategic response.

• This is not a modifier 25 ban. CMS is not proposing to eliminate modifier 25 or to prohibit same-day E/M billing with a procedure. Modifier 25 would still exist. The separately identifiable service standard would still apply. The change is a payment reduction on the lesser service, not a prohibition on billing it.
• The cut is not limited to the E/M. Under the proposal, CMS reduces the lesser-valued service, regardless of whether that is the E/M visit or the procedure. In a scenario where a high-level E/M (99215) is paired with a low-value procedure, the procedure would be cut, not the E/M.
• This is a proposed rule, not a final rule. CMS proposed and then withdrew a similar provision in 2019. The public comment period is open until September 14, 2026, and the final rule expected in November could narrow, delay, or remove the provision entirely. Planning for the worst while commenting against it is the appropriate dual-track approach.
• The reduction applies only within the same practice. If the E/M visit is furnished by a different practice than the one performing the procedure, the reduction would not apply under the current language. This matters for urology practices that refer patients to affiliated surgical centers where billing runs through a separate entity.

In-House Billing vs. Outsourced Under the New Rules

The proposed modifier 25 reduction does not change the clinical documentation requirements, but it does raise the stakes for getting the billing workflow right. A practice with in-house billing staff needs to ensure that those staff members understand the new payment logic, can model the per-encounter impact, and can identify which code pairs in the practice’s volume are most affected. A practice using an outsourced billing company needs to verify that the company is tracking the rule, has modeled the impact, and has a plan for claims processing changes if the provision is finalized.

One question we hear constantly from practice managers is whether their billing company is actually following regulatory developments or just processing claims reactively. A rule like this is a useful test. If your billing partner has not flagged the modifier 25 provision, has not modeled the revenue impact, and has no plan for the January 1 effective date, that is information worth acting on. For practices comparing bilateral modifier rules and other modifier-specific billing challenges in urology, the pattern is the same: the practices that collect more are the ones whose billing teams anticipate changes rather than discover them on a remittance advice.

CPT codes and descriptors are maintained by the American Medical Association and are provided here for reference. Payment amounts in this article are estimates based on a proposed rule and are subject to change in the final rule, so verify against current CMS guidance, the Medicare Physician Fee Schedule, and payer policies before billing.

Frequently Asked Questions

Next Steps

• Review the AUA’s summary of the CY 2027 PFS proposed rule for urology-specific impact details and monitor the AUA’s comment submission.
• Model the revenue impact using your practice’s actual modifier 25 volume and code pair data before the September 14 comment deadline.
• If your current billing partner has not flagged this provision, use our free matching service to connect with a urology billing company that stays ahead of regulatory changes.