What Is the Proposed Modifier 25 Payment Cut for ENT?
As of August 2026, the CMS CY 2027 Physician Fee Schedule proposed rule (CMS-1848-P) includes a provision that would reduce Medicare payment by 50% on any evaluation and management visit billed with modifier 25 on the same day as a procedure carrying a global period. For otolaryngology, CMS projects this change would contribute to a 9% overall payment decrease, making ENT one of the two hardest-hit specialties. The comment period closes September 14, 2026.
The survey numbers are clear. An AAO-HNS survey of 1,406 otolaryngologists released on August 19, 2026 found that 80% believe the proposed cut would reduce seniors’ access to specialty care, and 67% said they would have to see fewer Medicare patients.
ENT is disproportionately affected. Otolaryngologists perform diagnostic and surgical procedures alongside office visits on nearly every encounter. Nasal endoscopy, flexible laryngoscopy, and tympanostomy tube procedures routinely require a separately identifiable E/M visit, and every one of those same-day claims would be subject to the 50% reduction.
This is proposed, not final. CMS is accepting public comments through September 14, 2026, and the agency withdrew a nearly identical proposal in the CY 2019 rulemaking cycle after significant pushback from specialty societies.
What the AAO-HNS Survey Found
On August 19, 2026, the American Academy of Otolaryngology-Head and Neck Surgery released survey results from 1,406 member otolaryngologists collected between July 28 and August 13, 2026. The findings paint a direct picture of how ENT practices anticipate responding to the modifier 25 payment reduction if CMS finalizes it in the November 2026 final rule.
Eight out of 10 respondents said the proposed cut would reduce access to care for Medicare beneficiaries. More than two-thirds, 67%, said they would have to see fewer Medicare patients. Fourteen percent said they would stop accepting Medicare entirely. Respondents identified several potential responses: taking on more commercially insured patients, reducing services or staffing, joining larger health systems, or closing practices.
The AAO-HNS warns the consequences would be particularly severe in rural and underserved communities where practices have less flexibility to absorb further Medicare cuts. The Academy and nearly 20 national physician and patient organizations in the Same Day Care Coalition are urging CMS not to finalize the payment reduction.
In our experience matching ENT providers with billing partners, the modifier 25 question is already the first thing practice managers ask about when evaluating their 2027 revenue projections. The survey data confirms what we hear every week: this is not an abstract policy discussion for otolaryngology. It is a direct threat to the same-day care model that ENT practices are built around.
Which ENT Procedures Are Most Affected?
The modifier 25 cut applies any time a physician bills a separately identifiable E/M visit on the same day as a procedure with a 0-day, 10-day, or 90-day global period. In ENT, that covers nearly every diagnostic and minor surgical encounter. A diagnostic nasal endoscopy (CPT 31231) performed during a visit for chronic sinusitis, followed by a separately identifiable evaluation of a new complaint, is one of the highest-volume modifier 25 scenarios in otolaryngology.
A flexible laryngoscopy (CPT 31575) performed to evaluate hoarseness, with a same-day E/M for a separate ear complaint, is another everyday example. Tympanostomy tube insertion (CPT 69436) under general anesthesia with a same-day pre-operative evaluation billed as a distinct E/M visit is a third. Every one of these claim pairs would trigger the 50% reduction on the lower-valued service under the proposed rule.
The volume matters. ENT practices do not perform these procedures occasionally. A typical otolaryngologist may perform four to eight endoscopies per clinic day alongside office visits. When you multiply a 50% reduction on the E/M component across hundreds of encounters per month, the cumulative revenue loss is substantial. This is why CMS’s own impact analysis singles out otolaryngology alongside dermatology as the specialties most negatively affected.
Providers often come to us after noticing a slow decline in collections without a clear cause. Under this proposal, the cause would be visible from day one, but the solution is not as simple as seeing more patients. The economics of the same-day visit change fundamentally when one service is paid at half.
Before and After: How the Cut Changes ENT Billing
The following table shows how the proposed 50% modifier 25 reduction would change Medicare payment for common ENT same-day scenarios, using 2026 non-facility RVU values and the proposed 2027 non-QP conversion factor of $32.84.
| ENT Same-Day Scenario | E/M Code | 2026 Payment (Both Full) | 2027 Proposed (50% Cut) | Revenue Loss Per Claim |
| Nasal endoscopy (31231) + office visit | 99213 | $286 | $240 | -$46 |
| Flexible laryngoscopy (31575) + office visit | 99213 | $260 | $214 | -$46 |
| Cerumen removal (69210) + office visit | 99213 | $168 | $130 | -$38 |
| Nasal endoscopy (31231) + level 4 visit | 99214 | $349 | $286 | -$63 |
| Stroboscopy (31579) + office visit | 99213 | $312 | $266 | -$46 |
These figures are illustrative estimates based on published RVU values and the proposed conversion factor. Actual reimbursement varies by locality, payer, and contract. The pattern, however, is consistent: the E/M component drops to half, and the loss compounds across volume.
If your ENT practice needs help modeling the revenue impact of the proposed modifier 25 cut or preparing for 2027 billing changes, we connect you with billing companies that specialize in otolaryngology.
What Should ENT Practices Do Before September 14?
The CMS comment period on the CY 2027 Physician Fee Schedule proposed rule closes on September 14, 2026. After that date, CMS will review all public comments and issue the final rule, expected in November 2026. If finalized, the modifier 25 payment reduction takes effect January 1, 2027. Here is what ENT practices should do now.
1. Pull your modifier 25 claims data. Run a report on all claims from the past 12 months where your practice billed an E/M service with modifier 25 alongside a procedure with a global period. Count the total number of encounters and the total E/M revenue from those encounters. That number, reduced by 50%, is your exposure.
2. Identify your highest-volume same-day code pairs. For most ENT practices, the top pairs will be 31231 + 99213, 31575 + 99213, and 69210 + 99213. Rank them by frequency and calculate the per-claim and annual loss for each.
3. Submit a public comment to CMS. Any individual or organization can submit a comment on regulations.gov under docket CMS-1848-P. The AAO-HNS has published a resource page with guidance for otolaryngologists. Personalized physician comments carry significant weight with CMS, and physician pushback was directly credited with CMS withdrawing a similar proposal in the CY 2019 rulemaking cycle.
4. Contact your congressional representatives. The Capitol switchboard is (202) 224-3121. The AAO-HNS and the Same Day Care Coalition are asking legislators to urge CMS to withdraw the modifier 25 provision.
5. Review your commercial payer contracts. Some commercial payers already apply their own modifier 25 reductions. If CMS finalizes this policy, commercial plans may follow. Understanding your current payer mix and contract terms now positions you to negotiate before the shift.
6. Talk to your billing partner. Whether you bill in-house or outsource, your billing team needs to model the impact and prepare workflow adjustments. Across the billing companies we vet, the ones already running these projections for their ENT clients are the ones that will be ready in January.
Common Misreadings of This Proposal
Since the proposed rule was released on July 14, 2026, we have seen several recurring misunderstandings of what the modifier 25 change actually does. Getting these wrong leads to either panic or complacency, both of which cost the practice.
Misreading: The cut applies to all modifier 25 claims. Not exactly. The proposed 50% reduction applies specifically when an E/M service billed with modifier 25 is furnished on the same day as a procedure with a 0-day, 10-day, or 90-day global surgical period. Modifier 25 claims that do not involve a same-day global-period procedure are not affected by this specific provision.
Misreading: This is a done deal. It is not. This is a proposed rule, and the comment period closes September 14, 2026. CMS proposed a nearly identical modifier 25 cut in the CY 2019 Physician Fee Schedule, received significant opposition, and did not finalize it. The outcome depends on the volume and quality of public comments.
Misreading: The cut only affects Medicare. Directly, yes, but commercial payers watch Medicare payment policy closely. When CMS changes a payment methodology, commercial plans often follow within one to two years. The most common issue we see providers run into is assuming commercial contracts are insulated from Medicare rule changes. They are not.
Misreading: The 9% payment decrease is entirely from modifier 25. The 9% projected impact on otolaryngology includes the modifier 25 reduction, the conversion factor decrease, and practice expense methodology changes. The modifier 25 piece is the largest single driver, but it is not the only one.
In-House vs. Outsourced Billing Under This Change
The proposed modifier 25 reduction does not change what billing work needs to happen. Every same-day encounter still requires a separately identifiable E/M visit documented to payer standards, accurate modifier application, and clean claim submission. What changes is the economics: the revenue generated per same-day encounter drops, which directly affects whether the cost of billing that encounter is justified.
For practices billing in-house, this means staff time spent on same-day documentation and claims generates less revenue per unit of effort. The administrative burden remains the same, but the return shrinks. Practices that are already stretched thin on billing staff will feel this first.
For practices using an outsourced billing partner, the question becomes whether the billing company is proactively modeling the impact and adjusting its revenue projections for its ENT clients. One question we hear constantly from practice managers is whether their billing company is tracking the proposed rule. If the answer is no, that is a signal the relationship may not be equipped for what 2027 brings.
In our experience matching ENT providers with billing partners, the practices that navigate payment policy changes best are the ones whose billing company functions as a strategic partner, not just a claims processor. A billing partner that flags the modifier 25 exposure, models the revenue impact, helps submit a CMS comment, and adjusts workflows before January 1 is worth more than a billing partner that processes clean claims but never looks up from the queue.
Frequently Asked Questions
What is modifier 25 in ENT billing?
Modifier 25 is a CPT modifier appended to an evaluation and management code when a physician performs a significant, separately identifiable E/M service on the same day as a procedure. In ENT, it is used when a provider evaluates a patient for one complaint and performs a diagnostic or surgical procedure for a separate issue during the same visit.
How much would ENT practices lose under the proposed modifier 25 cut?
The loss depends on the practice’s modifier 25 claim volume. CMS projects a 9% overall payment decrease for otolaryngology under the 2027 proposed rule, which includes the modifier 25 reduction, conversion factor changes, and practice expense adjustments. Individual practice impact varies based on Medicare patient volume and procedure mix.
Is the modifier 25 payment cut final?
No. As of August 2026, the modifier 25 reduction is a proposed rule, not a finalized policy. CMS is accepting public comments through September 14, 2026, and the final rule is expected in November 2026. CMS proposed a similar cut in 2019 and withdrew it after public comment.
When would the modifier 25 cut take effect?
If finalized in the November 2026 rule, the modifier 25 payment reduction would take effect on January 1, 2027, for all Medicare claims.
Does the modifier 25 cut affect commercial insurance?
The proposed rule applies only to Medicare. However, commercial payers frequently follow Medicare payment policy changes. Some commercial plans already apply their own modifier 25 reductions or same-day service payment adjustments, and additional plans may adopt similar policies if CMS finalizes the change.
How do I submit a comment to CMS on the proposed rule?
Comments can be submitted electronically on regulations.gov under docket CMS-1848-P before September 14, 2026. The AAO-HNS has published guidance and template resources for otolaryngologists at entnet.org.
What ENT procedures trigger modifier 25 most often?
The highest-volume ENT procedures billed alongside a modifier 25 E/M visit include diagnostic nasal endoscopy (CPT 31231), flexible laryngoscopy (CPT 31575), cerumen removal (CPT 69210), and tympanostomy tube insertion (CPT 69436). Any procedure with a global period paired with a separately identifiable E/M visit is affected.
Did CMS try this before?
Yes. CMS proposed a nearly identical modifier 25 payment reduction in the CY 2019 Physician Fee Schedule proposed rule. After significant opposition from specialty societies during the public comment period, CMS chose not to finalize the provision. The AAO-HNS and the Same Day Care Coalition are pursuing the same strategy in 2026.
Next Steps
If your ENT practice bills Medicare procedures alongside same-day E/M visits, the proposed modifier 25 cut affects your revenue directly. Review the CPT 31231 billing guide and the CPT 31575 billing guide to understand the code pairs most affected, and model your exposure before the September 14 comment deadline.
Whether you handle billing in-house or work with an outsourced partner, the 2027 proposed rule demands a billing strategy review now, not after the final rule publishes in November.
ENT Billing Services connects otolaryngology practices with vetted billing companies that specialize in ENT coding, modifier compliance, and revenue cycle management. Billing Service Quotes has connected more than 2,000 providers across all 50 states, with over 15 years in medical billing and rates starting as low as 2.95%. Get matched in 30 minutes.
