Executive Summary

• Practice Expense Methodology: American Association of Clinical Endocrinology (AACE) supports improving PE valuation transparency but opposes replacing the AMA/RUC process with a CMS-developed methodology without clear evidence of deficiencies, specialty input, and a transparent appeals process. Any changes should protect independent practices, advance site neutrality, and avoid further disadvantaging cognitive specialties such as endocrinology.
• Duplicate Laboratory and Imaging Testing: AACE supports efforts to reduce unnecessary duplicate testing but believes the primary driver of duplicate services is the lack of interoperability between healthcare systems. CMS should focus on improving access to prior test results rather than addressing this issue through Physician Fee Schedule payment reductions or penalties. 
• Reduced Payment for Same-Day E/M Services and Procedures: AACE strongly opposes the proposed 50% payment reduction for same-day E/M services and procedures, citing a lack of evidence that meaningful duplication of work occurs. The policy would discourage coordinated, patient-centered care, increase patient burden, and particularly harm specialists managing complex patients who travel long distances for care.
• Conversion Factor Reduction: AACE remains concerned that ongoing Medicare payment reductions are occurring while practice costs continue to rise. The organization urges CMS to pursue sustainable physician payment reforms that preserve access to care and protect practice viability.
• Remote Patient Monitoring (RPM): AACE supports RPM as a valuable tool for chronic disease management but recommends reducing administrative barriers that limit adoption by smaller practices. Rather than restricting third-party RPM vendors, CMS should establish quality, compliance, and transparency standards to ensure accountability and protect beneficiaries.
• E/M Visit Complexity Add-On (G2211): AACE opposes replacing the current flat-rate G2211 payment with percentage-based modifiers tied to E/M level and ACO participation. The proposal undermines the code’s purpose, creates inequitable payment differences unrelated to resource costs, increases administrative complexity, and may penalize practices transitioning into value-based care models.
• Fine Needle Aspiration (CPT 10005/10006): AACE strongly supports CMS’s proposal to increase valuation for thyroid and other image-guided FNA procedures and urges adoption of the RUC-recommended values without reduction. Appropriate reimbursement is essential to maintain beneficiary access to timely, office-based diagnostic procedures that can prevent more invasive and costly interventions.

Practice Expense Methodology

American Association of Clinical Endocrinology (AACE) appreciates CMS’s goal of improving the accuracy and transparency of practice expense (PE) calculations. However, AACE has concerns regarding CMS’s proposed transition away from reliance on AMA survey-derived practice expense data toward a methodology increasingly developed and controlled by CMS. Although the current AMA/RUC process has opportunities for improvement, replacing an established process that incorporates direct specialty input with a CMS-developed methodology does not inherently guarantee greater accuracy. CMS already has the authority to review RUC recommendations and is not required to accept the values recommended through the RUC process. Rather than replacing the existing process, CMS should identify specific deficiencies and work collaboratively with the AMA, specialty societies, and other stakeholders to improve the current methodology.

Before implementing a substantial change in PE methodology, CMS should provide greater transparency regarding areas in which its empirical data differ materially from RUC recommendations or existing PE values. This should include examples of codes or services for which CMS believes the current methodology produces inaccurate values and the data supporting that conclusion. An important strength of the RUC process is the opportunity for physicians and other professionals with direct expertise in the services being valued to participate in the valuation process. Any alternative CMS methodology should therefore establish a formal mechanism for meaningful input from the specialties that actually furnish the affected services. CMS should also establish a transparent reconsideration or appeals process through which stakeholders can identify potential errors in data, assumptions, or calculations before significant payment changes are implemented.

AACE supports efforts to reduce inappropriate payment differentials based solely on site of service when comparable services require comparable resources. Site-neutral policies could help level the playing field for independent physician practices and reduce incentives for consolidation. However, CMS should ensure that changes to PE methodology do not inadvertently disadvantage private practices, particularly smaller practices that may lack the economies of scale available to large health systems. Any revised methodology should appropriately recognize legitimate practice expenses while advancing the goal of greater site neutrality.

Finally, CMS should evaluate whether the current budget-neutrality framework disproportionately shifts resources away from cognitive and nonprocedural services when new procedural technologies or other services are added to the Physician Fee Schedule. Cognitive specialties such as endocrinology rely heavily on evaluation and management and other nonprocedural services, and continued redistribution of finite Physician Fee Schedule resources may adversely affect the sustainability of these specialties and patient access to their services. AACE encourages CMS to examine the cumulative impact of budget-neutrality adjustments on cognitive and nonprocedural specialties and consider approaches that better preserve appropriate relativity and payment for these essential services.

Duplicate Laboratory and Imaging Testing

AACE recognizes that unnecessary duplicate laboratory and imaging testing can contribute to healthcare costs and supports efforts to improve the availability and sharing of prior test results. However, CMS should address interoperability barriers first rather than use payment policy to penalize physicians or restrict patients’ access to medically necessary testing. Physicians frequently practice in an environment in which laboratory and imaging results remain difficult to access across healthcare systems and electronic health record platforms. Physicians and patients should not face financial or administrative consequences for interoperability limitations outside of their control.

CMS and other federal agencies should prioritize requirements that enable reliable, timely exchange of laboratory and imaging results among EHR vendors, laboratories, imaging facilities, and healthcare organizations. Placing responsibility for preventing duplicate testing primarily on individual physicians or practices does not address the underlying problem and could result in denied testing, delays in care, and unnecessary confusion for Medicare beneficiaries.

Even with improved interoperability, repeat testing may be clinically appropriate. Prior results may be outdated, incomplete, unreliable, obtained using a different methodology, or require confirmation before an important clinical decision. AACE strongly recommends that CMS not implement payment reductions, denials, or other financial penalties related to duplicate. Any future policy should preserve physician clinical judgment and ensure that patients retain access to repeat testing when medically necessary.

Reduced Payment for Same-Day E/M Services and Procedures

AACE strongly opposes a blanket reduction in payment when a separately identifiable E/M service and a procedure are performed on the same day. The existing CPT and RUC processes are designed to evaluate the physician work and practice expenses associated with individual services. CMS should not presume that providing an E/M service and procedure on the same day results in duplication of physician work or practice expense. Before reducing payment, CMS should provide empirical evidence demonstrating that meaningful overlap or efficiencies actually occur and are sufficient to justify the proposed reduction. 

This policy could also create unintended barriers to coordinated, patient-centered care. Medicare beneficiaries, particularly those in rural or underserved areas, may travel significant distances to receive specialty care and often benefit from having multiple services or specialty visits coordinated on the same day. This is especially true for diabetes care and management, which increasingly requires a team-based approach involving endocrinologists, advanced practice providers, diabetes educators, registered dietitians, nurses, PharmDs addressing medication access issues, nephrologists, cardiologists, and other practitioners as clinically appropriate. Payment policy should reflect patients’ need to access the full care team without artificial barriers. Reducing payment for appropriately provided same-day services could create incentives to separate care across multiple days, increasing travel, time away from work or family, and other burdens for patients. This would also run counter to broader efforts to encourage coordinated care, including through ACOs and other value-based care models. In diabetes care, patients may appropriately receive diabetes self-management education and training (DSMT) services and physician evaluation and management services on the same day to improve access, reinforce treatment plans, support adherence, and ensure that education is integrated with the clinician’s assessment and management decisions. A payment policy that discourages practices from furnishing these coordinated services together could create unnecessary barriers for Medicare beneficiaries who need timely diabetes education as part of an ongoing, multidisciplinary plan of care.

Thyroid nodule evaluation provides a relevant endocrinology example. During an E/M visit, an endocrinologist may determine that a thyroid fine needle aspiration is clinically indicated and, when feasible, perform the procedure that day. The physician work required to safely perform the FNA is not necessarily reduced because the procedure occurs on the same day as the E/M service. A payment reduction could instead create an incentive to schedule the procedure on a separate day despite there being no clinical reason to do so.

This concern is not theoretical. Endocrinology practices, particularly regional referral centers and academic medical centers, often care for patients who travel long distances because specialized endocrine services may not be available closer to home. In these circumstances, same-day coordination can allow patients to receive evaluation, diagnostic procedures, diabetes education, medication-access support, and related specialty care during a single trip. A same-day payment reduction would effectively penalize clinicians and practices that organize care around the realities of patient travel, workforce shortages, and limited local specialty access, even when doing so reduces patient burden and supports timely, comprehensive care. Requiring separate visits for services that are clinically appropriate to provide on the same day would increase travel costs, time away from work or caregiving responsibilities, and delays in care, while reducing access to diabetes education and other services that are essential to effective chronic disease management. CMS should therefore carefully consider the impact of this proposal on multidisciplinary, team-based care models that rely on coordinated same-day encounters among physicians, advanced practice providers, diabetes educators, nurses, and other members of the care team.

If CMS identifies specific procedures for which empirical evidence demonstrates meaningful duplication of physician work or practice expense when performed with an E/M service, those services should be evaluated individually through the established valuation process rather than through a broad, across-the-board payment reduction. AACE therefore recommends that CMS not finalize the proposed 50% reduction and instead evaluate any potential overlap on a code-specific basis using empirical evidence and input from the specialties furnishing those services. Any final policy should preserve patient access to coordinated, same-day care and avoid undermining team-based models that improve continuity, adherence, and high-quality management of diabetes and other complex endocrine conditions.

Conversion Factor Reduction

AACE remains concerned about continued instability in Medicare physician reimbursement, particularly as physician practices face increasing costs for clinical staff, supplies, technology, regulatory compliance, and other expenses necessary to provide patient care. Under the CY 2027 proposed rule, the qualifying APM conversion factor would decrease from $33.57 in CY 2026 to $33.17 in CY 2027, a 1.19% reduction, while the non-qualifying APM conversion factor would decrease from $33.40 to $32.84, a 1.68% reduction.

A major contributor to these reductions is the expiration of the temporary 2.5% conversion factor increase provided for CY 2026. While AACE recognizes that CMS does not have the statutory authority to permanently extend this temporary increase, its expiration highlights the larger structural problem with Medicare physician payment: physician reimbursement continues to face downward pressure while the costs of operating a medical practice continue to increase.

AACE encourages CMS to use its available administrative authority to avoid unnecessary payment reductions and to evaluate the cumulative impact of payment policy changes on physician practices and Medicare beneficiary access to care. As CMS considers policies such as conversion factor reductions, practice expense revisions, and reductions for same-day E/M services and procedures, these changes should be assessed holistically to understand their combined effect on practice sustainability, patient access, and the delivery of high-quality care.

Remote Patient Monitoring

AACE supports remote patient monitoring (RPM) as an important tool for managing chronic diseases, including diabetes and other endocrine conditions. However, current administrative and compliance requirements can make it difficult for smaller physician practices to implement RPM independently, increasing reliance on third-party vendors.

AACE encourages CMS to streamline unnecessary administrative requirements so that smaller and independent practices can more readily provide RPM services directly. At the same time, the growth of third-party RPM vendors raises concerns regarding quality, clinical oversight, and appropriate billing. Rather than restricting the use of third-party vendors, CMS should consider establishing minimum quality, compliance, and transparency standards for vendors participating in Medicare, potentially through a CMS certification or qualification process. Such an approach could preserve access to innovative RPM services while ensuring appropriate accountability and protecting Medicare beneficiaries and the integrity of the program.

E/M Visit Complexity Add-On (HCPCS Code G2211)

Under the current methodology, G2211 is paid as a single, flat add-on amount whenever a clinician bills an office/outpatient E/M visit that reflects the additional resource costs of serving as the continuing focal point for a patient's care, regardless of the level of the underlying E/M visit. CMS designed it this way deliberately: the inherent complexity and continuity-of-care costs G2211 was created to capture do not scale with visit intensity, so a uniform payment — rather than one tied to the E/M code level — was the appropriate valuation approach. G2211 recognizes the complexity and longitudinal nature of managing chronic conditions and maintaining ongoing patient relationships, including the continuing clinical judgment, care planning, communication, and coordination required for patients with complex endocrine conditions.

The CY 2027 proposed rule would abandon that approach. CMS proposes to replace the flat add-on with a modifier paid at 16% of the corresponding E/M code's value for most practitioners, and a separate modifier paid at 32% of the corresponding E/M code's value for practitioners participating in the Medicare Shared Savings Program or the LEAD Model. We oppose this change for the following reasons:

First, it reintroduces the intensity bias G2211 was created to correct. A percentage-of-base-code modifier necessarily pays more, in absolute dollars, for higher-level E/M visits and less for lower-level visits — even though the continuity-of-care resource cost G2211 recognizes does not vary with visit intensity. This is the exact problem CMS's original G2211 policy was designed to avoid, and reversing it undercuts the code's stated purpose.

The proposal penalizes exactly the visits G2211 was meant to support. Many of the stable, longitudinal primary care and chronic disease management visits that most clearly reflect an ongoing patient-physician relationship are billed at lower E/M levels. Under a percentage-based modifier, these visits would receive a smaller absolute add-on than they do today, while higher-acuity visits receive a larger one — an outcome at odds with the policy's goal of supporting primary care and continuity of care.

If adopted, it creates a two-tiered payment structure unrelated to resource costs. Doubling the modifier value for MSSP and LEAD Model participants (32% versus 16%) values identical continuity-of-care work differently based solely on a practice's ACO contracting status, not on the resource costs actually incurred in furnishing the visit. This is a significant departure from the resource-based relative value methodology that underlies the physician fee schedule, and it risks disadvantaging independent, rural, and other non-ACO-affiliated practices that furnish the same longitudinal care but lack access to ACO participation.

Furthermore as proposed this penalizes the very practices CMS is trying to encourage into ACOs, due to well-known enrollment timing. Becoming a recognized MSSP participant is not immediate: new ACO participant TINs are generally added to a participant list only once a year, and a practice applying today typically cannot become an active, recognized participant until the following January 1 performance year at the earliest — a lag of roughly seven to twelve months from application, and closer to two years for a practice that misses a given year's application window. The LEAD Model, as a brand-new model beginning January 1, 2027, will have its own onboarding and attestation process with similar or greater lead time. Under the proposed rule, a practice that has already committed to, or is actively pursuing, ACO participation would continue to receive only the 16% modifier throughout this onboarding period, even though it has taken on the operational investment and accountability of joining an ACO. This timing gap means the proposal would penalize newly forming and newly joining ACOs precisely when they are investing the most in the transition, undermining CMS's own stated goal of encouraging ACO participation.

CMS has not presented a resource-cost justification for the change. The proposed rule does not, to our knowledge, include data or analysis demonstrating that continuity-of-care costs scale proportionally with E/M code level, nor does it justify why ACO participation — rather than the clinical and administrative work actually performed — should determine the value of this add-on. Without such a record, the change appears to be a policy-driven reallocation rather than a valuation grounded in resource costs, which is inconsistent with the statutory basis for the fee schedule.

This proposal adds administrative complexity without a clear benefit. Replacing a single, well-understood add-on code with two conditional modifiers increases documentation and billing burden and creates new compliance risk around correct modifier selection and ACO-status determination, with no clear offsetting benefit to patients or practices. CMS should also avoid additional restrictions or exclusions that prevent appropriate use of G2211 when other medically necessary services are furnished during the same encounter. Excluding G2211 when services such as medication administration, preventive assessments, or other ancillary services are performed may fail to recognize the ongoing complexity of care management where a separately identifiable E/M service reflects continuity of care and longitudinal management. The code should remain available when the E/M service is distinct and appropriately documents the clinician’s role in managing complex endocrine conditions over time.

For these reasons, we urge CMS to finalize CY 2027 policy that retains G2211 as a flat-rate add-on payment, applied uniformly regardless of E/M visit level or ACO participation status. If CMS wishes to further incentivize participation in the Medicare Shared Savings Program or other alternative payment models, we encourage the agency to do so through MSSP-specific payment mechanisms rather than by differentially valuing a code intended to recognize a resource cost that all practices incur equally when they serve as a patient's continuing source of care. At minimum, if CMS proceeds with any version of this policy, it should account for MSSP and LEAD Model onboarding timelines so that practices actively transitioning into an ACO are not penalized during the period — often a year or more — between initiating participation and formal recognition as an ACO participant.

Fine Needle Aspiration (CPT Codes 10005 and 100006)

CPT codes 10005 and 10006 have been undervalued since reductions applied beginning with the CY 2019 Physician Fee Schedule. In the years since, clinical societies — including the American Association of Clinical Endocrinology and the American Thyroid Association — have consistently documented that the current valuation does not adequately reflect the physician work, technical skill, and clinical judgment required to safely and accurately obtain diagnostic tissue, particularly for thyroid nodules and other superficial and deep-seated lesions suspicious for malignancy. We appreciate that CMS has now proposed to revisit this valuation as part of the CY 2027 misvalued code review, and we urge the agency to finalize the RUC-recommended increases without reduction.

Accurate valuation of these codes matters for patient care, not just practice finances. Image-guided FNA is the first-line, minimally invasive diagnostic tool for evaluating thyroid nodules and other lesions suspicious for cancer, and its appropriate use routinely avoids the need for more invasive, more expensive, and higher-risk alternatives such as open or core-needle surgical biopsy. Continued undervaluation of 10005 and 10006 discourages physicians from performing these procedures in the office setting, which in turn can delay diagnosis, increase downstream Medicare spending by shifting patients toward costlier surgical alternatives, and reduce beneficiary access — particularly in rural and other underserved areas where in-office FNA may be the only readily available option.

We also support CMS's related proposal to update the pricing of the portable ultrasound equipment used in image-guided FNA. Equipment pricing that has not kept pace with the actual cost of the technology used to safely and accurately localize target lesions further compounds the undervaluation of these services and should be corrected alongside the work RVU update.

For these reasons, we respectfully urge CMS to finalize, without reduction, the proposed work RVU increases for CPT codes 10005 and 10006 and the associated equipment repricing in the CY 2027 Medicare Physician Fee Schedule final rule. We further encourage CMS to continue monitoring the adequacy of FNA valuation going forward to ensure Medicare beneficiaries retain timely access to this essential, minimally invasive diagnostic service.

Thank you for the opportunity to provide comments on the CY 2027 Medicare Physician Fee Schedule proposed rule. AACE appreciates CMS’s consideration of these recommendations and welcomes the opportunity to continue working with the agency to advance payment policies that support access to high-quality, coordinated endocrine care for Medicare beneficiaries.

Sincerely, 

Dace L. Trence, MD, MACE
AACE President