Why Medicare's 2027 change to Same-Day Evaluations and Procedures Matters to All Patients

Oct 1

3 min read

If you have ever seen your physician for a new medical problem and had a procedure performed during that same visit, changes in insurance reimbursement may affect you — even if you are not a Medicare patient.

What is a same-day evaluation and procedure?

When a patient comes to the office, the physician may need to evaluate the problem, perform an examination, review treatment options and make a medical decision about the appropriate treatment. Sometimes, that evaluation leads to a procedure being performed during the same appointment.

These are potentially two distinct services:

The evaluation: examining the patient, establishing or confirming a diagnosis, discussing treatment options and making medical decisions.
The procedure: performing the treatment itself.

Medicare has traditionally allowed and covered a separately identifiable evaluation and management (E/M) service to be reported on the same day as a procedure when the evaluation is significant, medically necessary and goes beyond the usual work included in the procedure. This is commonly reported with modifier 25.

Why does Medicare matter if I have commercial insurance?

Medicare sets many of the standards used throughout the healthcare reimbursement system. Most commercial insurance companies use Medicare guidelines, CMS policies and Medicare reimbursement methodologies as a basis for their own payment policies, although individual commercial plans may have different requirements.

As a result, changes made by CMS can have consequences well beyond Medicare patients.

CMS has proposed a significant change for 2027 that would reduce or eliminate payment for certain separately identifiable E/M services performed on the same day as procedures with 0-, 10- or 90-day global periods.

Some commercial insurers are already adopting similar reimbursement reductions.

What does this mean for our patients?

To provide consistency for our patients and staff, Appleton Plastic Surgery Center has established an internal policy that we will follow the two-appointment approach for all insurance carriers.

When an evaluation is needed before determining that a procedure is appropriate, the evaluation will take place at one appointment and, when appropriate, the procedure will be scheduled for a separate visit.

This means that instead of:

Evaluation → medical decision-making → procedureOne visit

you may have:

Evaluation and treatment planningVisit #1

ProcedureVisit #2

There are several reasons for this approach. It allows adequate time for the physician to evaluate the condition, discuss treatment options and answer questions without the pressure of performing a procedure during the same appointment. It also provides a consistent approach regardless of which insurance company a patient has.

Please understand the potential cost

Patients with insurance should be aware that two separate appointments may result in two separate copayments or other out-of-pocket expenses.

For example, if your insurance plan requires a copayment for an office visit, you may have:

Copay #1 — Evaluation appointment

Copay #2 — Procedure appointment

Your actual financial responsibility will depend on your individual insurance plan, deductible, coinsurance and benefits. We recommend contacting your insurance company if you have questions about your specific coverage.

The bottom line

Changes to Medicare reimbursement policies can have effects throughout the healthcare system because commercial insurance companies frequently model their payment policies on Medicare and CMS guidelines.

Although these policies may originate with Medicare, their effects can reach patients with commercial insurance as well.

At Appleton Plastic Surgery Center, our goal is to provide appropriate, thorough care while maintaining a consistent process for all of our patients. Our two-appointment policy means that when an evaluation is needed before a procedure, patients should expect the evaluation and procedure to occur at separate visits, regardless of their insurance carrier.

We also want our patients to understand the potential financial impact in advance: if your insurance requires copayments, you may be responsible for a copayment at each visit.

If you have questions about your insurance benefits or expected out-of-pocket costs, please contact your insurance company before your appointment.