2027 - CMS proposes 50% pay cut for 25 modifier visits
Started by heybrother
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BeaverBlade
Full Member
Well because if it passes you know it’ll just set the standard for more commercial insurances.
it would really kill podiatry I don’t think it’s an exaggeration to say that
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BeaverBlade
Full Member
Everyone get on it
BeaverBlade
Full Member
does ortho appreciate the damn work we're putting in? kudos to APMA. my congress person actually emailed me back. he told me to do the public comment thing, but if a vote ever comes to him on it he'd vote against that proposal
This was the form letter I got from Cornyn the last time I mailed him. Should have bought my vote bro.
No money for health care but unlimited funds for forever wars and ICE. These people are ****ing clowns.
BeaverBlade
Full Member
i mean the healthcare spending is outrageous but if we cut out the middle men in insurance or at least limit their involvement i'm sure we'd cut costs nationally like at least 50%.
Mark cuban has been talking about this a lot. Not a reps friend
I love Mark Cuban. I'm currently uninsured (using Crowd Health) while my business get's going. Was previously paying $2K a month in premiums.
3 months of Metoprolol is $50 at CVS and $12 at Mark Cuban's pharmacy. Probably some savings to be had with goodrx, but that's still BS.
I'm switching from Eliquis which is $360 self pay to Pradaxa which is $23 there.
Through some sort of miracle my town's big hospital system has great self pay pricing. Had labs done. List price - $460. Self pay price - $46.
Paid $140 for an office visit. The head of the mammogram department told me a self pay mammogram is like $150, but if they submit to insurance they start at something like $2-4K.
3 months of Metoprolol is $50 at CVS and $12 at Mark Cuban's pharmacy. Probably some savings to be had with goodrx, but that's still BS.
I'm switching from Eliquis which is $360 self pay to Pradaxa which is $23 there.
Through some sort of miracle my town's big hospital system has great self pay pricing. Had labs done. List price - $460. Self pay price - $46.
Paid $140 for an office visit. The head of the mammogram department told me a self pay mammogram is like $150, but if they submit to insurance they start at something like $2-4K.
sdupre_apma
Full Member
For what it's worth, APMA is working on this one directly (link at the bottom here). I've put together some numbers on the scope of impacts this might have for podiatry O/O E/M billing. I'll share some statistics on SDN in the next few days once I run some last checks on results.
www.apma.org
Editing to note that people have linked this already above (apparently I hadn't refreshed the page in a minute).
APMA Continues Fight Against Medicare Same-Day Care Cuts Proposal
Proposed Modifier 25 Cuts Today, APMA President Patrick DeHeer, DPM; APMA CEO Meghan McClellan; and members of the APMA advocacy team met directly with Centers for Medicare & Medicaid Services (CMS) officials to urge the
Editing to note that people have linked this already above (apparently I hadn't refreshed the page in a minute).
I use his pharmacy often for patients who get gouged by their insurances.
Penlac for 10 bucks.
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Great you are wasting 10 of their dollars instead of 30 of their dollars?
Cost Plus sells itraconazole at a very favorable price and with no risk of prior authorization.
More like no risk of working
Itraconazole is either as effective as terbinafine, or slightly less effective depending on what study you read. It is still multiple times - probably 6x more effective than Penlac.
If you aren't going to prescribe terbinafine or itraconazole - prescribe fluconazole 400 mg once per week (2x200 mg pills). Its off label for onychomycosis in the US, but its used in Europe and it does work albeit its less effective than terbinafine/itraconazole in most studies. Patients who are unwilling to take terbinafine are often willing to take this because the dosing is so infrequent and many women have already used it and know its not difficult to use. It is 3-5x more effective than Penlac which I would rate generously at 10%.
BeaverBlade
Full Member
It’s ciclopirox 8% because it works 8% of the time
If it prevents me from watching some girl cry because her nails are ****ed or prevents a bad Google review, I’ll run the charade for a bit. Sometimes they don’t want the truth.
That really is one of my favorite podiatry jokes.
Had another patient yesterday.
Insane health problems, heart problems, b/l leg stents, toe wound not healing.
"Hey can you trim his big toenail? I kind of made a mess of it trying to cut it the other day"
Bro he's got MAJOR other problems what the F**** man.
Insane health problems, heart problems, b/l leg stents, toe wound not healing.
"Hey can you trim his big toenail? I kind of made a mess of it trying to cut it the other day"
Bro he's got MAJOR other problems what the F**** man.
I've seen penlac work but it becomes your lifestyle [and yes this is memable "penlac lifestyle"]. Patients have to do it daily and a residue will build up so they have to either file it down or wash it off with acetone. For a highly neurotic patient, it works well. For your average 72 year old guy who comes in with his daughter Karen, I wouldn't bother.
Penlac is a good drug to prescribe when you want to end an unwanted fungus conversation and GTFO the room as quickly as you can.
Penlac is a good drug to prescribe when you want to end an unwanted fungus conversation and GTFO the room as quickly as you can.
BeaverBlade
Full Member
I feel bad for those patients. I help them out any way possible with nail care when they have severe PAD
Side note, anyone else super paranoid of diabetes because of all the patients we see? I don’t consume like any sugar since I’ve been a resident.
Same, and that's good. Diet and exercise could fix/prevent a lot of podiatry problems. You should practice what you preach. This is why I don't trust fat doctors
Sugar isn't bad in its own right. A lot of foods you buy in the store have added sugar to make them extra-delicious and less satiating, this way you consume more and buy more. This doesn't satisfy the textbook definition of an addictive substance, but you know what's happening here...
Just read your nutrition labels, eat 25g fiber per day, get 8h sleep every night, 30 min of zone 2 cardio daily, drink your milk, take your vitamins, and say your prayers and your 24-inch pythons will run wild over type 2 diabetes
Is this @BubbaWub ?
You forgot MOAR PROTEIN.
but yes you should be fibermaxxing.... Generally I recommend generics, but metamucil 4 in 1 is leaps and bounds better than the Walmart version
My child has been eating cottage cheese. #SoProud
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Yes we took care diabetics. I don’t think surgery on them , with liability can be worth it
Fat doctors - lot podiatrists
Ur hospital employed. Stay in ur lane. They come to see us because yall told them you can’t treat their nails
This is a daily occurrence in PP. Especially when a family member brings in a trainwreck that they suddenly pretend to start caring about
Speak now or forever hold your peace.
BeaverBlade
Full Member
Just submitted my comment everyone needs to submit!!!!
Someone wrote:
---
Yo Dr. Oz,
When I do my toenail trimming I need to bill a 99213 with it to get $$$. Don't shut my game down playa.
--
Is this you beaverblade?
😉
---
Yo Dr. Oz,
When I do my toenail trimming I need to bill a 99213 with it to get $$$. Don't shut my game down playa.
--
Is this you beaverblade?
😉
You left out callus with those two!!??! Common out there
sdupre_apma
Full Member
OK, a little bit back I promised some statistics, here we go...
So, APMA is very concerned about this legislation and asked me to run a bunch of numbers so we could have hard figures to bring to the OMB/White House representatives whom APMA was reaching out to.
TLDR: CMS PSPS data suggest that modifier -25 is a routine part of Medicare podiatry E/M billing, not a marginal occurrence. In 2025, approximately 43% of Medicare FFS office/outpatient E/M services submitted by DPMs carried modifier -25, up slightly from about 42% in 2024. The rate was actually higher for new-patient E/M services (about 46% in both years) than for established-patient services. These estimates are robust to CMS small-cell suppression.
Overall: Modifier -25 is common in Medicare podiatry E/M billing. The combined rate was 41.5% in 2024 and 42.6% in 2025. Roughly 4 in 10 Medicare FFS office/outpatient E/M services billed by DPMs carry modifier -25.
This was based on data from CMS that involved small count cells being suppressed (standard identity protection stuff). I ran a bunch of sensitivity analyses and CMS cell suppression does not materially change that conclusion. The sensitivity analysis produced approximately 41.2%–41.9% overall in 2024 and 42.2%–42.9% in 2025. For new-patient E/M, the ranges were approximately 45.6%–46.8% in 2024 and 45.5%–46.7% in 2025. The analysis found only modest movement under deliberately conservative suppression assumptions.
The financial footprint of O/O E/M is substantial. Medicare FFS payments attributed to podiatry O/O E/M were approximately $521.5 million in 2024 and $522.3 million in 2025, essentially flat year to year. Of that, our fuller analysis found approximately $215.8 million in 2024 and $220.9 million in 2025 associated with O/O E/M services carrying modifier -25.
Use care interpreting/discussing E/M as a share of podiatry spending. O/O E/M represented 20.0% of all podiatric (specialty-48) PSPS Medicare payments in 2024 and 16.2% in 2025. One key caveat here, the apparent decline is largely a denominator effect: drug/product-related payments increased dramatically, including the BETOS “other drugs” category from roughly $1.08B to $1.74B. A service-focused sensitivity excluding major product/supply categories put O/O E/M at 35.5% in 2024 and 36.6% in 2025.
So, APMA is very concerned about this legislation and asked me to run a bunch of numbers so we could have hard figures to bring to the OMB/White House representatives whom APMA was reaching out to.
TLDR: CMS PSPS data suggest that modifier -25 is a routine part of Medicare podiatry E/M billing, not a marginal occurrence. In 2025, approximately 43% of Medicare FFS office/outpatient E/M services submitted by DPMs carried modifier -25, up slightly from about 42% in 2024. The rate was actually higher for new-patient E/M services (about 46% in both years) than for established-patient services. These estimates are robust to CMS small-cell suppression.
Overall: Modifier -25 is common in Medicare podiatry E/M billing. The combined rate was 41.5% in 2024 and 42.6% in 2025. Roughly 4 in 10 Medicare FFS office/outpatient E/M services billed by DPMs carry modifier -25.
This was based on data from CMS that involved small count cells being suppressed (standard identity protection stuff). I ran a bunch of sensitivity analyses and CMS cell suppression does not materially change that conclusion. The sensitivity analysis produced approximately 41.2%–41.9% overall in 2024 and 42.2%–42.9% in 2025. For new-patient E/M, the ranges were approximately 45.6%–46.8% in 2024 and 45.5%–46.7% in 2025. The analysis found only modest movement under deliberately conservative suppression assumptions.
The financial footprint of O/O E/M is substantial. Medicare FFS payments attributed to podiatry O/O E/M were approximately $521.5 million in 2024 and $522.3 million in 2025, essentially flat year to year. Of that, our fuller analysis found approximately $215.8 million in 2024 and $220.9 million in 2025 associated with O/O E/M services carrying modifier -25.
Use care interpreting/discussing E/M as a share of podiatry spending. O/O E/M represented 20.0% of all podiatric (specialty-48) PSPS Medicare payments in 2024 and 16.2% in 2025. One key caveat here, the apparent decline is largely a denominator effect: drug/product-related payments increased dramatically, including the BETOS “other drugs” category from roughly $1.08B to $1.74B. A service-focused sensitivity excluding major product/supply categories put O/O E/M at 35.5% in 2024 and 36.6% in 2025.
BeaverBlade
Full Member
No. I’m trying to help our cause not hurt it. Hopefully that’s not real.
Its not 😉
BeaverBlade
Full Member
everyone better get the comments in just a few hours
BeaverBlade
Full Member
I hope everyone commented on this. If you didn’t don’t complain if we get paid 50% on our procedures
So when do we figure out the final decision on this?
So when do we figure out the final decision on this?
The final rule is usually in November. I think this ruling is going to cause a lot of exhaustion for a lot of physicians.
1. We are virtually guaranteed a rate cut.
2. The MD/DOs are freaking out about changes to G2211 ie. making it a modifier rather than a code.
3. And everyone is freaked out about the 50% cut.
The dangerous slippery slope will be that they don't implement a 50% cut, but instead implement a small cut and then try to expand it through time.
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