Medicare’s modifier 25 fight should not spill into the Annual Wellness Visit
Medicare’s proposal to pay only half of a separately identifiable evaluation and management visit billed with modifier 25 on the same day as a 0-, 10- or 90-day global procedure has triggered a familiar political reflex: if one specialty is asked to absorb a cut, another should be brought into the same penalty box. The American College of Surgeons has pushed that logic by arguing that CMS should look at other same-day cognitive services, with the Medicare Annual Wellness Visit serving as the leading example. But the comparison collapses on contact with how the AWV actually works.
The AWV is a preventive benefit, not a bundled surgical step. It is built around risk assessment, screening, medication review, cognitive evaluation, depression screening, fall-risk review, a five- to 10-year prevention schedule, and referrals or counseling when needed. It is not designed to absorb the diagnosis and management of active disease. A problem-oriented office visit layered on top of an AWV is not duplicative work; it is the moment when primary care does the work the AWV deliberately leaves out.
The AWV is preventive care, not a hidden surgical package
The ACS companion analysis points to volume and payment totals, noting that the AWV code G0439 appears with an office visit nearly 5 million times in 2024 and represents about $630 million in allowed charges. It also says only 37% of AWV claims are billed alone. Those numbers are real, but volume does not convert preventive care into a surrogate surgical package. The fact that the visit often uncovers chronic disease, medication problems, or new symptoms is proof that the service is doing what it was built to do.
One sentence cuts through the accounting argument: the AWV does not include treating hypertension, adjusting insulin, titrating heart failure therapy, or working up a new complaint.
That is the clinical boundary CMS already recognizes. The agency’s own guidance allows an AWV and a significant, separately identifiable, medically necessary E/M service to be paid together when the problem visit is reported with modifier 25. In plain terms, CMS already distinguishes between prevention and treatment on the same day. The current proposal to haircut modifier 25 payments in the setting of global surgical procedures does not change the nature of the AWV itself.
Same-day surgery logic does not map onto primary care
The surgical argument rests on the idea that the global package already contains preprocedure work, so a same-day E/M might be double counted. Whether that logic is persuasive for surgery is a separate question. It does not translate well to the AWV for three straightforward reasons.
First, there is no global package attached to the AWV. There is no bundled postservice period and no built-in preoperative evaluation hidden inside it. The AWV pays for prevention, screening, and coordination, not for longitudinal disease management over the next 90 days.
Second, the goals are different. A surgical consultation and the procedure aim toward one operation. The AWV aims toward prevention, risk stratification, and the early detection of problems that would otherwise sit untreated. When a clinician identifies depression, cognitive decline, poor diabetes control, or unsafe medication use during an AWV, the follow-on work is not a duplicate. It is the clinical payoff.
Third, the patients are not abstract billing units. Many beneficiaries arriving for an AWV live with diabetes, chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, depression, polypharmacy, and specialist recommendations that need reconciliation. Asking primary care to complete the preventive checklist while ignoring a hemoglobin A1c of 9.4 or a blood pressure of 168/96 would distort the entire purpose of the visit. Returning another day for “cleaner” billing creates friction for older adults and delays needed care.
Time assumptions are not the same as clinical work
The ACS argues that billing G0439 with 99214 implies 94 minutes of physician time and more than 100 minutes of clinical staff time. That calculation comes from relative value assumptions, not from what necessarily happens in the exam room. Since 2021, office E/M codes can be selected by either total time or medical decision-making. A 99214 billed on moderate medical decision-making does not require a minute-by-minute tally that can simply be added to the AWV.
The AWV itself is intentionally team based. It can be furnished in part by health educators, registered dietitians, and other licensed professionals under physician supervision, and the patient can complete the health risk assessment before the encounter. Staff time and physician cognitive work are not interchangeable, and combining them into a single inflationary figure misstates how the service is delivered.
Primary care should not be singled out for using a complexity-based office visit next to a preventive encounter while Medicare tolerates vast gaps in surgical global reporting. RAND’s claims-based analysis for CMS found that in 2019, 96.5% of procedures with 10-day global periods had no associated postoperative visit reported, and only 38% of expected postoperative visits tied to 90-day global procedures were actually reported. A specialty system that can bill for visits that often do not appear in claims should be cautious about treating primary care’s documented chronic disease work as overvaluation.
Primary care already carries the burden of longitudinal care
AWVs are performed almost entirely by family physicians, internists, and advanced practice providers. That makes the service unmistakably a primary care function. It is often the one annual visit when medications, specialist notes, discharge summaries, screenings, goals, and care gaps are finally reviewed together. It is also the visit where preventive medicine intersects with accountability, since primary care is measured on quality benchmarks, ACO performance, and risk-adjusted outcomes.
The financial context matters here. Primary care remains among the lowest-paid sectors in medicine, while surgical and procedural specialties generally sit at the top of compensation surveys. Medicare physician payment has also been eroded by inflation over time, and both proposed 2027 conversion factors remain below 2026 levels. Under budget neutrality, moving money away from one service means taking it from another. Shifting the burden of a surgical payment dispute onto the AWV would not correct a structural problem; it would simply transfer pressure to the lowest-paid clinicians doing longitudinal care.
The AWV pays roughly $138 nationally, with no patient cost-sharing. A 99214 pays roughly $136. Together, the combined payment of about $274 reflects a preventive review plus active disease management for a Medicare patient with multiple chronic conditions. That is not a windfall. It is the cost of keeping an older, medically complex patient under continuous care.
CMS should keep preventive care out of this cut
CMS has better tools than a blunt reduction. Modifier 25 can be audited through documentation when it is abused. Preventive services should remain outside any same-day payment reduction tied to surgical global packages. And if CMS wants to revisit primary care valuation, it should do so directly rather than smuggling a new cut into the AWV through a surgical policy debate.
The rulemaking already says it wants to move Medicare toward preventive rather than reactive medicine. Penalizing the AWV when a clinician also treats active disease would push practices in the opposite direction: split visits, fewer problems addressed, or a checkbox wellness encounter with no follow-through. None of that helps beneficiaries with real disease burden. The policy question is not whether surgery reimbursement is under strain; it is whether CMS should repair that strain by discounting preventive and chronic care that primary care already delivers in the same visit.