CMS released the proposed 2027 Medicare physician fee schedule (proposed rule), which contains several important provisions affecting allergy practices. While the proposal includes another reduction in the conversion factor and several policy changes that warrant close attention, it also presents significant opportunities for our specialty. Most notably, CMS has responded to years of ACAAI advocacy by requesting public input on modernizing its allergy immunotherapy policies for CPT code 95165. The Advocacy Council is carefully reviewing the proposal and preparing/submitting formal comments to CMS on the proposed rule.
Two conversion factors decrease from 2026
CMS proposes to implement two reduced conversion factors for 2027:
- One for qualifying alternative payment model (APM) participants.
- One for practitioners who are not qualifying APM participants.
The proposed 2027 qualifying APM conversion factor would be $33.1693, representing a 1.19% decrease from the 2026 conversion factor of $33.5675.
The proposed 2027 nonqualifying APM conversion factor would be $32.8409, representing a 1.68% decrease from the 2026 conversion factor of $33.4009.
Allergy immunotherapy – CPT code 95165
For purposes of CPT code 95165, CMS is examining:
- Whether Medicare’s current definition of a dose reflects contemporary practice.
Medicare currently defines a dose as “a 1cc aliquot,” regardless of the amount administered to the patient. The Advocacy Council continues to believe that CMS’s definition of a dose does not reflect clinical standards of care and imposes a billing structure that is inconsistent with real-world practice. This inconsistency places a significant administrative burden on allergy practices, which must navigate varying payer definitions of a “dose” under CPT code 95165. Medicare’s definition of a dose not only complicates billing and documentation processes but also increases the risk of dosing errors, potentially compromising patient safety. Therefore, the Advocacy Council will request that CMS rescind this definition and instead adopt the dose definition set forth by the AMA CPT codebook.
Every allergist needs to reinforce our efforts by submitting your own comment letter. Download this sample comment letter as your starting point. Add personal data and describe why immunotherapy is important to your patients, how their quality of life has changed, and/or about patients whose care has been delayed or denied because of insurance policies. You can submit your comment letter via regular mail or electronically. Sept. 14 is the deadline.
- Whether the 30-dose-per-claim Medically Unlikely Edit (MUE) should be replaced with an annual dose limit.
An MUE is the maximum number of units of service reported for a CPT code on the vast majority of appropriately reported claims by the same provider for the same beneficiary on the same date of service. If there are concerns about overutilization of CPT code 95165, CMS can address this through annual (rather than daily) limits with a higher limit for the first year of treatment that includes the build-up phase. To that end, the Advocacy Council will recommend CMS adopt reasonable annual limits on doses billed under CPT 95165:
- Up to 150 doses per year during the first year of therapy (including the build-up phase)
- Up to 120 doses per year after the first year of therapy (during maintenance therapy)
Practice expense (PE) methodology
CMS is proposing several changes to how it calculates PE RVUs. Under the 2027 Proposed Rule, CMS proposes to:
- Allocate indirect PE using both the work RVU and the clinical labor RVU for all services, with the exception of codes with 010- and 090-day global periods.
- Phase out the Indirect Practice Cost Index (IPCI) from the calculation of the PE RVUs over a two-year transition period. In the first year, only half of the measured variation in the IPCI would be applied to the indirect allocator. In the second year, the IPCI would no longer be applied.
- Implement a PE stabilization adjustment policy that generally limits annual PE RVU increases or decreases to 5%.
According to CMS’ analysis, approximately 95% of the specialty’s allowed charges ($147 million of $154 million in total allowed charges) are attributable to non-facility (i.e., office-based) services. CMS estimates that the PE RVU proposals would only have a slight negative impact on non-facility charges (-1%). However, the agency estimates no impact on non-facility charges when analyzing proposed changes to all three RVUs (work, PE, and malpractice). CMS estimates there will be little combined impact on allergy practices. Notably, CMS’ chart below is based upon aggregate estimated allowed charges summed across all services furnished by physicians, practitioners, and suppliers within a specialty. Therefore, the figures below are averages and do not represent what is happening to a particular service.
Table D-B5: CY 2027 PFS Estimated Impact on
Total Allowed Charges by Specialty
| (A) Specialty |
(B) Total: Non-Facility/Facility |
(C) Allowed Charges (mil) |
(D) Impact of Work RVU Changes | (E) Impact of PE RVU Changes | (F) Impact of MP RVU Changes | (G) Combined Impact |
|---|---|---|---|---|---|---|
| Allergy / Immunology | Total | $154 | 0% | -1% | 0% | 0% |
| Non-Facility | $147 | 0% | -1% | 0% | 0% | |
| Facility | $7 | 1% | 0% | 0% | 1% |
To assist practitioners in evaluating the potential impact of these proposals, the Advocacy Council has developed two comparative spreadsheets; a more nuanced understanding of the impact of the PE RVU methodology on specific CPT codes commonly reported by allergists and a comparison the final 2026 and proposed 2027 RVUs and national payment amounts for commonly reported CPT codes.
Note: figures do not reflect geographic adjustments. Please note these are proposed policies, not finalized policies. We expect the final rule to be published in early November.
Download the College’s Advocacy Council’s spreadsheet that compares the final 2026 RVUs with the proposed 2027 RVUs for commonly reported CPT codes.
For a chart comparing the final 2026 and proposed 2027 national payment amounts for commonly reported CPT codes, download this spreadsheet.
Remote monitoring
CMS proposes several changes to the Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services:
- Established patients only. CMS proposes to limit RTM services to established patients.
- Initiating visit requirement. Practitioners would have to furnish a separately reportable, face-to-face (in-person or telehealth) initiating visit before RPM or RTM services begin and must discuss RPM or RTM with the patient at that visit.
- Supervision and staffing. Currently, RPM or RTM services may be outsourced to third-party companies that provide services via telephone and online contact. CMS now proposes to only allow payment for RPM or RTM services when:
- The clinical staff is a direct employee of the practice.
- The clinical staff are under the general supervision of the billing practitioner.
- All other requirements of the “incident to” regulations at 42 C.F.R. § 410.26 are met.
In other words, the Proposed Rule would not allow contracting to third-party companies. This proposal would adversely impact allergy practices currently relying on outside vendors to assist with collecting, reviewing, and managing patient-generated data. The Advocacy Council will oppose this proposal.
CMS is also proposing to bundle the 17 current remote monitoring codes through the creation of new “G” codes that describe initial set-up and monthly monitoring/management for RPM and RTM, respectively.
E/M services
CMS proposes replacing the G2211 complexity add-on with two modifiers applied to the underlying E/M service:
- MOD1, valued at 16% of the base E/M code
- MOD2, valued at 32% of the base E/M code for practitioners in certain accountable care arrangements, including Shared Savings Program Accountable Care Organizations (ACOs)
CMS proposes to carry forward the existing limitation on billing G2211 (or, if finalized, MOD1 or MOD2) together with a modifier -25 E/M visit. Modifier -25 denotes a significant, separately identifiable office/outpatient (O/O) E/M visit by the same physician or other qualified health care professional on the same day as a procedure or other service.
Separately, CMS is proposing to reduce payment when a separately identifiable O/O E/M visit is furnished by the same physician (or a physician in the same group practice) on the same day as a 0-, 10-, and 90-day global procedure. Under this proposal, the most expensive service (either surgical or E/M visit) would be paid at 100%, and all other surgical procedure(s) or E/M visit(s) would be paid at 50%. Notably, allergy CPT codes are largely classified as “xxx” codes, indicating that the “global” concept doesn’t apply. Accordingly, most allergy services would not be impacted by this proposal.
Telehealth
CMS proposes to establish two new telehealth modifiers, BB and BC, effective Jan. 1, 2027. The modifiers do not affect payment. Rather, they are required on claims for telehealth services furnished through a virtual telehealth platform when the physician or practitioner contracts with (or has a payment arrangement with) the entity that owns the platform, and on claims for telehealth services furnished incident-to a practitioner’s professional service. CMS has indicated that more detailed guidance will be posted to the CMS website.
The 2027 Medicare Physician Fee Schedule Proposed Rule can be accessed here.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
