If you’ve ever gone to the dermatologist and had a suspicious spot removed on the same visit that you were examined by the doctor, you’ve had what Medicare calls a “modifier 25” visit. It’s one of the most common billing arrangements in medicine, and it’s now at the center of a fight that could change how fast seniors are seen and how much they pay out of pocket.
What Modifier 25 Actually Means
Take away the jargon and it's easy. Modifier 25 is a code doctors use when they do two different things on the same day. An office visit (the exam and decision-making) and a procedure (removing a mole, injecting a joint, draining a cyst, etc.) The modifier says to Medicare, "These were two separate services, not one,” so the doctor gets paid for both.
Things are going to change, though. Currently Medicare generally pays almost the full amount for each service. Starting January 1, 2027, a rule proposed July 14, 2026, by the Centers for Medicare & Medicare Services (CMS), will change. Whichever service is more expensive, the visit or the procedure, would still be paid at 100%. But everything else charged that day would be cut to 50%.
Both Sides, and What Happens Next
CMS says paying full price for both the visit and the procedure amounts to paying twice for overlapping work. Doctors disagree, arguing modifier 25 exists precisely to certify that the visit was separate and necessary. The AMA has joined the pushback, warning that a 50% Medicare pay cut would put physician practices at risk.
This wouldn't be the first time. CMS floated nearly the same idea in 2019 and dropped it after doctors made the same argument. Whether that argument wins again is still unclear.
For now, nothing is final. Public comments are open through Sept. 14, 2026, and groups like the American Podiatric Medical Association are urging members and patients to speak up. CMS could issue a final rule by November, with any change taking effect January 1, 2027. CMS isn't proposing to eliminate modifier 25, only to pay less for it.
Why Should Seniors Care?
This could affect seniors who frequently visit dermatology, podiatry, ophthalmology, orthopedics, OB/GYN, family medicine, and urgent care—the specialties that rely most on same-day visit-and-procedure combinations.
For instance, a dermatologist examines a new mole and, during the same visit, removes a precancerous lesion using a freezing technique. A diabetic foot's troublesome toenail is cut by a podiatrist; knee pain cortisone injection by an orthopedist. All of these are modifier 25 visits, and under the proposed rule, each would be compensated for about half of that encounter.
Practices have a few likely reactions when their compensation for bundling services is abruptly reduced, none of which are beneficial to patients:
- Dividing up visits. Instead of doing the exam and procedure in a single appointment, some practices might start scheduling two separate visits. This entails more doctor visits, more time off from work or transportation arrangements, and longer wait times for medical care.
- Longer delays and more crowded schedules. Practices may schedule fewer same-day visits if their financial viability is jeopardized, particularly in already overworked specialties like dermatology where new patient wait times can be months.
- Greater out-of-pocket costs. After meeting their Part B deductible, Medicare beneficiaries typically pay a 20% coinsurance. Patients may be required to pay two copays or coinsurance amounts rather than one if a visit is divided into two encounters rather than one.
- Stress on small practices. Physicians with a large number of Medicare patients who practice independently in specialties like podiatry and dermatology would be more affected by this cut than large hospital systems with other revenue streams. The number of Medicare patients that certain smaller practices can treat may be limited.
What You Can Do Now
If patients have a concern about this rule, they can submit comments to CMS during the open comment period, just as medical groups are pushing back.
Additionally, it may be worth contacting your doctor's office, particularly the specialists you visit often, to inquire about any anticipated modifications to their scheduling of combined appointments, preventing any surprises if the appointments are divided into two visits rather than one.
