Spine surgeons are tracking several Medicare reimbursement changes that could affect professional fees, ASC economics and future Part B payments.
Some are included in CMS’ proposed 2027 Physician Fee Schedule and outpatient payment rules. Another, the Ambulatory Specialty Model, has already been finalized and begins its first performance year Jan. 1.
Here are the payment pressures to watch.
The physician conversion factor would fall
CMS’ proposed 2027 Medicare Physician Fee Schedule would set the conversion factor at $32.84 for clinicians who are not qualifying advanced alternative payment model participants, down 1.68% from $33.40 in 2026. For qualifying APM participants, the proposed factor is $33.17, down 1.19% from $33.57.
CMS said much of the year-over-year decline reflects the expiration of a temporary 2.5% increase that applies only to 2026.
For spine and orthopedic practices, the potential impact extends beyond the conversion factor. CMS’ specialty-level analysis estimates orthopedic surgery payments would decline 7% from proposed RVU and coding changes. Neurosurgery and interventional pain management would each see estimated 2% declines.
The estimates are national averages and are separate from the proposed conversion factor reductions. Orthopedic leaders have warned the pressure could have implications beyond physician income.
“This is one of the most dangerous and severe situations I’ve seen in the 30-plus years I’ve been in practice,” Wilford Gibson, MD, president of the American Academy of Orthopaedic Surgeons, told Becker’s.
Same-day visits and procedures could be reimbursed differently
CMS is also proposing to reduce payment when a physician, or another physician in the same practice, provides a separately identifiable office or outpatient evaluation and management visit on the same day as a procedure with a 0-, 10- or 90-day global period.
Under the proposal, the highest-cost service would be paid at 100%. Other qualifying surgical procedures or E/M visits furnished that day would be paid at 50%.
For musculoskeletal practices, the policy could affect encounters in which a physician evaluates a patient and performs a qualifying procedure during the same visit.
Dr. Gibson expressed concerns regarding how lower reimbursement could make some same-day procedures financially difficult for independent practices.
Common spine pain procedures face ASC facility-payment cuts
CMS’ proposed outpatient and ASC rule includes a 2.4% average payment update for ASCs that meet applicable quality-reporting requirements. However, several high-volume spine pain procedures would see lower national ASC facility payments under the proposal.
Transforaminal epidural steroid injections, CPT 64483, and lumbar/sacral facet joint injections, CPT 64493, would each fall from $485.51 to $466.96. Lumbar/sacral radiofrequency ablation, CPT 64635, would decrease from $948.66 to $908.27, while interlaminar lumbar/sacral epidural injections, CPT 62323, would fall from $387.46 to $372.75.
The changes apply to ASC facility payments, not the surgeon’s Physician Fee Schedule professional payment for the services. However, spine surgeons have said the facility economics could influence where the procedures are performed.
“The numbers just won’t work for an ASC anymore; the facility overhead will eat up whatever reimbursement is left,” Issada Thongtrangan, MD, an endoscopic and minimally invasive spine surgeon at MicroSpine in Scottsdale, Ariz., told Becker’s.
Dr. Thongtrangan said his practice could respond by moving lower-acuity pain procedures into office-based procedure suites and reserving ASC capacity for more complex surgical cases.
Some spine specialists face future Part B payment risk under a mandatory model
Separate from the proposed payment rules, CMS’ Ambulatory Specialty Model is scheduled to begin Jan. 1.
The mandatory model includes select physicians treating Medicare patients with low back pain in designated geographic areas. Eligible specialties include neurosurgery, orthopedic surgery, anesthesiology, interventional pain management, pain management and physical medicine and rehabilitation.
The model does not reduce participating physicians’ payments in 2027 based on their 2027 performance. Instead, CMS will score participants on quality, cost, improvement activities and Promoting Interoperability.
A physician’s 2027 performance will determine the adjustment applied to Medicare Part B-covered professional services in 2029. Payment adjustments can range from a 9% decrease to a 9% increase in the first two payment years, 2029 and 2030, with a wider range in later years.
CMS has published a preliminary participant list and will use 2025 claims data to determine final eligibility for the 2027 performance year.
Mike Verdon, MD, a neurosurgeon in Dayton, Ohio, told Becker’s he is concerned some physicians on the preliminary list are unaware of the model.
“I know a lot of people that are and they don’t know,” Dr. Verdon said.
What happens next
The Physician Fee Schedule and OPPS/ASC changes remain proposals and could change before they are finalized.
Comments on the outpatient and ASC proposed rule are due Aug. 31, and comments on the Physician Fee Schedule proposed rule are due Sept. 14.
If finalized, the payment changes would take effect Jan. 1. The Ambulatory Specialty Model is on a separate track: Its first performance year also begins Jan. 1, but the first performance-based payment adjustments would take effect in 2029.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
