Significant coding and reimbursement changes are on the horizon for 2027, including the transformation of obstetrics billing as well as proposed revisions to professional services under the Calendar Year (CY) 2027 Medicare Physician Fee Schedule (MPFS). Below, we highlight important updates as well as a behavioral health coding and reimbursement challenge involving treatment of patients with certain types of depression.
HotStone Contents:
Maternity Care Changes
Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Changes
Spravato Therapy
MATERNITY CARE SERVICES
What the American Medical Association (AMA) describes as a “structural shift”, effective January 1, 2027, maternity care service codes and payment will reflect more contemporary practice patterns within obstetrics.[1] New clinical guidelines published by the American College of Obstetrics and Gynecology (ACOG) encourage maternity care professionals to tailor the frequency and monitoring schedule to the individual needs of pregnant women. Revised clinical recommendations do not necessarily align with what is perceived to be an outdated reimbursement methodology. Accordingly, the global maternity package has been overhauled and effectively unbundled into an entirely new coding paradigm which reflects distinct phases of obstetric care.[2]
Long awaited, as health systems have historically struggled to attribute practitioner work contributions under the current global reimbursement model, these changes have profound implications not only related to CPT code structure, but also documentation, clinical workflow, payer contracting and perhaps the most tangible, increasing revenue cycle complexity.
Where to begin?
Understanding the unbundled coding framework is critical and centers around four (4) distinct phases:
Antepartum Services
Labor Management
Delivery
Postpartum Services
Digesting definitions of each phase as well as the new code sets and their requirements is a fundamental first step with multiple new code additions as well as deleted codes. Accustomed to documenting within flowsheets, obstetrics practitioners will now be required to report evaluation and management (E/M) service codes for both antepartum and postpartum services. Understanding how these phases align with the 2021 and 2023 E/M framework could pose a steep learning curve.
Documentation considerations are paramount, such as capturing detail to include when labor management ends and delivery begins as newly defined for CY 2027 to facilitate proper code assignment. Other critical considerations include updating the charge description master (CDM), billing under differing practitioner models (employed vs. independent physician groups), increased claim volume along with the potential for an uptick in edits and denials with new same day visit rules as well as communication with payers relative to policy and reimbursement. Further, charge capture will be impacted under obstetric model revisions for pregnancies spanning calendar years 2026 and 2027.
Payer Variances
In an interesting twist, The Center for Medicare and Medicaid Services (CMS) has expressed concern that changes in maternity care code structure may impact clinical outcomes.[3] Under the 2027 MPFS, they have proposed new HCPCS Level II - G codes which reflect the existing global obstetrics coding and reimbursement methodology. Citing concern that adoption of the new CPT codes would be disruptive based on how the longstanding existing code structure is currently accounted for in clinical practice patterns, CMS is seeking comment on whether they maintain the current coding model. Subsequent to the release of the proposed rule, ACOG indicated that failure to use the uniform code set for obstetrics would undermine their efforts to tailor maternal care as well as much needed data collection. ACOG further expressed concern that misalignment between CMS and other payers introduces instability including the potential that payers may adopt varying policy and payment models.[4]
Get Ready: Operationalizing Changes
As the AMA has stressed that success will be predicated entirely on alignment both clinically and organizationally, and given the vast implications across health systems, SunStone is encouraging clients to consider how they will operationalize the revised billing model by January 1, 2027. To facilitate implementation of obstetric changes, organizations should evaluate their readiness across several key areas, including:
Provider, coder, and revenue cycle education
Documentation and workflow optimization
Coding and charge capture processes
CDM (i.e., Fee Schedule) updates and pricing strategies
Payer contracting and reimbursement considerations
Revenue cycle and denial management processes
Practitioner compensation and work Relative Value Unit (RVU) attribution
Transitional planning for cases spanning 2026 and 2027
Compliance, auditing, and payment validation activities
Early planning will help organizations mitigate operational disruption, maintain compliance, and support appropriate reimbursement during the transition to the revised maternity care payment methodology. SunStone is providing management consulting solutions to aid in transition support and facilitate implementation of obstetric changes. Timely implementation and consideration will ensure compliance and appropriate reimbursement during the transition period.
CY 2027 MPFS
In addition to maternal care services, proposed updates to other professional services under the CY2027 MPFS also have considerable reimbursement and clinical workflow implications across multiple specialties, the most significant of which are highlighted below:
Remote Patient Monitoring (RPM) and Remote Treatment Monitoring (RTM)
In response to the 2024 OIG Report indicating additional oversight of RPM is needed, CMS has proposed refinements to RPM and RTM services, putting forward new requirements which could alter how the service is executed and by whom.
First, to facilitate oversight and ensure the billing practitioner is actively involved, CMS proposed practitioners reporting RPM and RTM render a separately billable visit for the express purpose of initiating the remote service during which they evaluate clinical appropriateness and obtain patient consent.
Perhaps an even more profound change, however, is what has been proposed surrounding supervision. The OIG Report raised concern because clinical staff executing aspects of these services were found to have little to no established relationship with the beneficiary or other members of the care team and have little to no interaction with the office staff and billing practitioner.[5] CMS asserted that this model detracts from longitudinal, patient-centered care and undermines oversight by the billing practitioner and in turn the full scope of RPM service elements is not met. Therefore, CMS proposes to only allow payment for RPM and RTM when furnished by clinical staff employed by the practice, which represents a significant change. CMS clarified though that this does not mean that clinical staff must necessarily be located within the practice, predicated all other requirements of the incident-to regulations are satisfied, but they must remain under the general supervision of the billing practitioner.
Considerable changes have also been put forward to streamline the code structure, including changes in valuation, by way of four (4) new codes which describe initial setup and monthly monitoring of RPM and RTM, reducing the number of codes from seventeen (17) to four (4). Because the OIG Report raised questions relative to whether patients were receiving all required components of RPM and RTM service, by incorporating device supply, data transmission and treatment management into one (1) code, CMS maintains they could more readily ensure that these service elements are always provided.[6]
Visit Complexity
Several years into utilization of the visit complexity add-on HCPCS code G2211, CMS no longer believes that a flat rate reimbursement methodology accurately reflects the variation in work of the various E/M visit levels when a longitudinal patient-practitioner relationship exists. Rather, they assert visit complexity should reflect an increase to the base visit code that is proportional across all types of E/M visits. Therefore, CMS proposed a valuation of sixteen percent (16%) of the base E/M when a newly created modifier is appended to the claim while instructing the modifier would be applied under the same circumstances that HCPCS G2211 is currently billed.[7]
A second modifier is also proposed for use by Accountable Care Organization (ACO) participants with increased valuation to reflect the additional resource costs associated with accountable care, paying twice the rate of non-ACO participants, thirty-two percent (32%).
Mod 25 Payment Valuation
CMS has proposed to reduce payment by fifty percent (50%) when a separately identifiable outpatient or office E/M is furnished by the same practitioner or same group practice on the same day as a procedure due to likely duplication in payment when both are rendered on the same day. CMS is essentially citing that overlap exists when a practitioner renders an E/M visit on the same day as a procedure, thereby reducing payment associated with the perceived overlap.
This revised payment policy would allow one hundred percent (100%) of the most expensive service, which could either be the procedure or the E/M service, with all other codes paid at fifty percent (50%). As proposed, this would apply only to outpatient and office E/M, but CMS is seeking feedback relative to the application for inpatient E/M services as well.[8]
Primary Care Exception
Revisions to a long-standing policy limiting the levels of E/M services which could be billed in the absence of a teaching physician in certain settings, would facilitate payment of moderate and higher-level E/M codes. Under the primary care exception, CMS has proposed allowing more autonomy for resident physicians similar to flexibilities endorsed during the COVID-19 Public Health Emergency in which higher level E/M services could be billed under the teaching physician even if they did not personally evaluate the patient.[9]
Shared Visits
Shared medical visits are group appointments where multiple patients with a common chronic condition receive medical care together. To facilitate payment, CMS has proposed coding for shared medical appointments (SMA) in 60-minute sessions with a maximum of ten (10) beneficiaries per session, either in person or via telehealth for medical conditions which can be influenced by lifestyle change. Both the individual services provided to the patient and the group as a whole need to be captured in the medical record.
Citing conditions which are modifiable with lifestyle change such as diabetes mellitus, obesity, hypertension, and hyperlipidemia, SMA’s promote behavioral changes including diet, physical activity and self-management which can influence health outcomes. SMA’s are led and billed by a physician or Advanced Practice Practitioner (APP) and may involve clinical staff or auxiliary personnel.[10]
Advance Care Planning by Clinical Staff
In addition to the existing Advance Care Planning (ACP) codes, CMS has proposed two new G-codes to account for services furnished by clinical staff under the direct supervision of the billing practitioner. Current CPT codes 99497 and 99498 would apply only to time personally furnished by the billing practitioner. The proposed G-codes could be reported in conjunction with 99497 and 99498 when the applicable time thresholds are satisfied. CMS has proposed a work RVU of 1.00 for the first twenty (20) minutes of ACP services furnished by clinical staff, and 0.7 for each additional twenty (20) minutes of clinical staff time.
SPRAVATO TREATMENT
Prevalence of Spravato treatment is rising among patients with treatment-resistant depression. A nasal spray which is typically self-administered under the direct supervision of a healthcare team, providers are facing the complexities of compliant billing in providing this service and specifically how to capture the work and time of physicians and clinical staff, an area of notable misunderstanding and potential risk.
By way of relevant background, CMS acknowledged in the 2020 MPFS that there were no existing coding and payment structures describing the services and resources required to administer Spravato and created two (2) HCPCS “G” codes, which bundle the services of the physician, clinical staff, and the medication:
G2082 (Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation); (wRVU 0.7)
G2083 (Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation). (wRVU 0.7)[11]
In determining the interim final values for these codes, CMS used a building block methodology, using the values of several established codes, specifically CPT 99212 with a work RVU of 0.7 mirroring the work RVU attributed to G2082 and G2083. As the basis for the practice expense for these new codes, CMS relied on CPT codes 99415 and 99416 which are valued only to capture clinical staff rather than physician time.
The fact that the “G” codes are valued with the same work RVU as CPT 99212 suggests that CMS viewed this service as largely a clinical staff versus physician service. In fact, the American Psychiatric Association (APA) in a December 31, 2019 letter to the then CMS administrator Seema Varna appealed to CMS to increase the valuation of the prolonged clinical staff time (not physician time) given time required not only for observation and monitoring the patient, but time spent fulfilling the requirements of the REMS program, prior authorization for the medication and the safe storage, preparation and disposal of a controlled substance.
While the “G” codes are all inclusive of both physician and clinical staff work and time, commercial payers will typically allow the unbundling of this service and therefore the physician can bill an E/M provided that the documentation supports both the medical necessity for a problem-oriented E/M visit.
When Spravato is administered, multiple patients may be observed concurrently by clinical staff. The key issue and dilemma in billing an E/M with this service is that the physician can only bill for the time uniquely given to one patient at a time: both face-to-face or non-face to face. If the physician sees other patients in the office while one or more patients are receiving Spravato, overlapping time does not count. Therefore, routine billing of 99215 with prolonged service codes based on time for a single patient is not likely and could create compliance risk if physician time is inappropriately attributed to individual patients when patients are seen simultaneously. The required observation logs will support when the physician evaluated one or more patients and for how long.
SunStone acknowledges that the current coding structure established for the billing of Spravato treatment may undervalue both physician and clinical staff time and effort. Compliant billing of the physician’s work and time is challenging and for that reason, we have advised clients to bill an E/M based only on the complexity of the medical decision making (not time) and then bill for the prolonged clinical staff time.
SunStone Consulting offers comprehensive services geared to help hospitals, health systems and providers evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com, Joli Fitzgibbons, Senior Director at jolifitzgibbons@sunstoneconsulting.com or Cathy Archuleta, Senior Manager at cathyarchuleta@sunstoneconsulting.com.
[1] A Coding Primer: Previewing the CPT 2027 Restructure for Maternity Care Services Codes <https://www.ama-assn.org/membership/events/coding-primer-previewing-cpt-2027-restructure-maternity-care-services-codes>
[1] AMA Maternity Care Services, pages 1-13. <https://www.ama-assn.org/system/files/cpt-maternity-care-codes-guidelines.pdf>
[1]CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Maternity Care Services, page 40. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1]ACOG Payment in Practice: Updates on Obstetric Codes and Setting the Record Straight https://www.buzzsprout.com/2350276/episodes/19550849-updates-on-obstetric-codes-and-setting-the-record-straight?t=0
[1] OIG Additional Oversight of Remote Patient Monitoring in Medicare Is Needed, OEI-02-23-00260, September 2024, page 10. https://oig.hhs.gov/documents/evaluation/10001/OEI-02-23-00260.pdf
[1] CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Remote
Monitoring, page 51. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1] CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Evaluation and Management (E/M) Visit Complexity Add-On (HCPCS Code G2211), page 57. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1] CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Accounting for E/M Resource Overlap Between Stand-Alone Visits and Global Periods, page 67. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1] CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Revisions to Teaching Physician Policy Related to the Primary Care Exception, page 68. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1] CMS Physician Fee Schedule Proposed Rule 2027, Federal Register Vol.91, No. 135/Thursday, July 16, 2026/Shared Medical Appointment (HCPCS Code GSMAS), page 63. https://www.govinfo.gov/content/pkg/FR-2026-07-16/pdf/2026-14327.pdf
[1]CMS Physician Fee Schedule Final Rule 2020, Federal Register Vol. 84, No. 221, Friday, November 15, 2019/Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine (HCPCS Codes G2082 and G2083), page 536. https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other