On July 16, CMS published a significant Request for Information (RFI) to assess potential reforms to overhaul the American Medical Association’s (AMA’s) Current Procedural Terminology® (CPT®) coding system. The RFI was included in the Calendar Year (CY) 2027 Physician Fee Schedule Proposed Rule (CMS-1848-P).
Concerns about Conflicts, Patient Care, and Innovation
The RFI cites “longstanding concerns” raised by the Medicare Payment Advisory Commission (MedPAC) about over-reliance on a private organization with a financial interest in the CPT® and Relative Value Scale Update Committee (RUC) processes. CMS also suggests the processes may contribute to a “‘sick care’ system with limited emphasis on prevention and … inhibit progress on the Secretarial priority to Make America Healthy Again.”
CMS requests input on the “harms or challenges associated with AMA’s monopoly” as well as “potential improvements to patient care diverted or delayed … including inhibited innovations and acquisition/maintenance costs of CPT® licensure.” Notably, CMS also asks whether any alternatives to the CPT® and RUC processes exist or could be developed and adopted to maintain a more objective process, while considering the impact on innovation.
Alternative Coding Systems
CMS specifically seeks comments on the possible “benefits and drawbacks of paying for physician procedural services on the basis of the underlying International Classification of Diseases, 10th Revision (ICD-10) procedure code, as an alternative,” with services grouped or bundled into payment categories similar to other Medicare payment systems. The agency notes that a combination of CPT® and the Healthcare Common Procedure Coding System (HCPCS) codes were adopted through rulemaking as the current national coding standard and questions the need for additional rulemaking and a separate legal standard.
Congressional Focus on Costs and Improper Billing
The agency’s inquiry comes in the wake of congressional investigations launched by the Senate Health, Education, Labor, and Pensions (HELP) Committee and the House Committee on Oversight and Government Reform (OGR). The Senate HELP Committee has focused on how the current CPT® “monopoly” may increase costs within the healthcare system based on revenues generated through licensure and sales of ancillary services and materials. The House OGR Committee has questioned the complexity of CPT® coding and noted the potential for the system to be gamed through improper billing, upcoding, or other abuses.
What’s at Stake
Providers, manufacturers, and other stakeholders should recognize the potential for CPT® reform to cause major upheaval in the healthcare sector. Risks include incomplete and inaccurate federal data systems, bias toward bundled and packaged payments, and federally driven rate-setting, among others. Given the broad scope of the RFI, the potential impact of sweeping changes to the CPT® coding system, and related congressional interest, stakeholders should seriously consider taking this opportunity to inform CMS policy deliberations. The deadline for comments on the RFI and the Proposed Rule is September 14, 2026.