CMS Asks Whether CPT Should Stay the National Coding Standard

Buried on page 43952 of a 716-page proposed rule, CMS has asked the public a question it has never formally asked before: should the CPT code set continue to be the national standard for describing physician services at all? The request for information sits inside the CY 2027 Medicare Physician Fee Schedule proposed rule, published 16 July 2026 at 91 FR 43842, file code CMS-1848-P, RIN 0938-AV82, docket CMS-2026-2377. Comments are due 14 September 2026.

The RFI does not propose anything. It changes no code, no modifier and no rate. But the questions CMS chose to write down are unusually direct about a structure that every professional-fee coding operation in the country is built on top of, and the comment window is open now.

What CMS actually asked

The RFI appears in the rule’s table of contents as the “Current Procedural Terminology (CPT) Request for Information.” CMS sets out the history first — CPT introduced by the AMA in 1966; the CPT-4 fourth edition in 1977 establishing the five-digit numeric structure still in use; HCFA requiring HCPCS for physician services in 1983 and extending it to non-physician services in 1991, with HCPCS Level I treated as synonymous with CPT and Level II covering additional products, supplies and services.

Then it makes the legal point that the rest of the RFI hangs on. Following HIPAA, HHS defined the combination of HCPCS and CPT-4 as the nationally required medical data code sets at 45 CFR 162.1002(a)(5) — covering physician services, physical and occupational therapy, radiologic procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services, and transportation including ambulance services. CMS then observes, in its own words, that “there is no specification in the HIPAA statute regarding the manner in which these national coding sets may be used or how they may be combined, and only HHS interpretation, not the Act itself, mentions CPT.”

That is CMS pointing out that the thing making CPT mandatory is a regulation HHS wrote, not a statute Congress passed — and a regulation can be revisited.

The five questions, in substance:

Evidence of harm from CPT licensing. CMS asks what evidence exists regarding “the harms or challenges associated with AMA’s monopoly over CPT-4 licenses for health care entities,” specifically asking commenters to cite improvements to patient care that were diverted or delayed, inhibited innovations, and the acquisition or maintenance costs of CPT licensure. (The phrase “monopoly” is CMS’s, in the published text.)

Medical necessity in code creation. Whether the generation of CPT-4 codes follows any process of identifying medical necessity, and what other populations, sites of care or international health systems could inform such a process.

Alternatives to CPT-4 as the standard. If CMS revisited 45 CFR 162.1002(a)(5) in future rulemaking, what alternatives exist — and, pointedly, whether CMS would need to specify a separate legal standard at all “or could CMS allow for private competition to supplement the existing CPT-4 coding standard.”

Alternatives to the CPT Editorial and RUC processes. What more objective processes exist or could be developed, and how they would support or inhibit innovation.

Paying off ICD-10-PCS instead. The benefits and drawbacks of paying for physician procedural services on the basis of the ICD-10 procedure code, and how ICD-10-PCS services could be grouped or bundled into payment categories along the lines of MS-DRGs or OPPS APCs.

Why CMS says it is asking

The preamble is candid about the motivation. New CPT codes originate with the CPT Advisory Committee, made up of members of national medical specialty societies seated in the AMA House of Delegates; once defined, a code is assigned a relative value through the AMA RUC, established in 1992 after Medicare moved to the resource-based relative value scale. CMS notes “longstanding concern expressed over the Federal reliance on a private organization with such an obvious conflict of interest as providing information on the time and resource requirements to conduct physician services when this information may influence their own payment.”

It cites two external sources for that concern. MedPAC has raised it for nearly two decades, and CMS quotes its position that the agency has “over-relied on specialty societies with a financial stake in the process,” along with MedPAC’s recommendation that CMS establish a separate group of experts to make payment recommendations. CMS also cites the 2025 National Academies report Improving Primary Care Valuation Processes to Inform the Physician Fee Schedule, which recommends alternatives to the RUC for primary care valuation and alternative sources of data collection.

CMS frames the whole inquiry as part of the Secretarial “Make America Healthy Again” priority, arguing that historic reliance on the CPT and RUC process may have contributed to a system with limited emphasis on prevention.

The rates, for context

The same rule carries the CY 2027 payment numbers, and they are not good news. Since 2026, section 1848(d)(1)(A) of the Social Security Act has produced two conversion factors rather than one: a qualifying APM conversion factor for services furnished by qualifying APM participants, and a nonqualifying APM conversion factor for everyone else. For 2027 CMS projects:

Qualifying APM CF: a decrease of $0.40 (−1.19 percent) from the current $33.4009.

Nonqualifying APM CF: a decrease of $0.56 (−1.68 percent) from the current $33.5875.

These are projections in a proposed rule, not final figures — the final conversion factors are set in the final rule, normally in early November. Note also that the gap between the two conversion factors widens under this proposal, which is the intended design: it is the mechanism by which qualifying APM participation is rewarded. OIRA has determined the rule economically significant under section 3(f)(1) of Executive Order 12866.

The other RFI worth reading: duplicate testing

The same rule contains a second request for information that will land harder on laboratory and imaging operations than on physician offices: an RFI on duplicate laboratory testing, imaging, and result sharing and interoperability.

CMS’s framing is that imaging data and test results are frequently siloed inside the acquiring system’s EHR, that treating clinicians often do not know the prior result exists, and that the consequence is duplicative testing, increased cost and — for imaging — unnecessary radiation exposure. It then lists four mechanisms it is “exploring” for addressing duplicative payment:

Clarifications to billing instructions for laboratories and imaging centres on what counts as a duplicate test.

Local MAC edits resulting in non-payment or reduced payment for duplicate tests.

Payment integrity levers to recoup payments from providers and suppliers that performed duplicate tests.

Frequency limitations on certain tests where clinically appropriate.

CMS cites an existing example: LCD L33996 (Vitamin D Assay Testing), under which further testing after a documented deficiency is medically necessary only to confirm adequate replacement, with annual testing thereafter depending on indication. CMS states it believes other tests should similarly be subject to frequency limits, and asks which ones — and what exceptions are needed so beneficiary access is not restricted, giving trauma, stroke and evolving emergencies as cases where repeat imaging is clinically appropriate. It specifically asks how practitioners should communicate clinical justification for a repeat test.

It also asks whether there is a time period within which a repeat test should be “automatically” treated as duplicate and subject to payment consequences. For anyone who codes repeat testing, that is the question to answer — see CPT modifier 91 for how repeat clinical laboratory tests are distinguished today, and modifier 59 and the X modifiers for the distinct-procedural-service problem this would collide with.

The interoperability half of the RFI leans on the statutory definition added by section 4003 of the 21st Century Cures Act (Pub. L. 114-255), which inserted a definition of interoperability at section 3000(10) of the Public Health Service Act — including that qualifying technology “does not constitute information blocking.” Institutions with a mature position on information blocking exceptions already have most of the material for a response.

What this means, and what it does not

Nothing in either RFI is binding. No coding practice changes on 15 September, and CPT-4 remains the required code set under 45 CFR 162.1002(a)(5) until and unless HHS amends that regulation through separate notice-and-comment rulemaking, which it has not proposed. Anyone telling you to prepare for a post-CPT world is getting ahead of the document.

What has changed is the status of the question. A federal payer has put on the public record, in a rulemaking, that it regards the CPT licensing arrangement as a monopoly worth gathering evidence against, that it considers the RUC conflicted, and that it is willing to consider ICD-10-PCS-based grouping as an alternative basis for paying physician procedural services. RFIs frequently precede proposals by a year or more, and sometimes lead nowhere. But an RFI is the only stage at which the evidence base gets built, and the entities that respond are the ones whose facts end up in the eventual preamble.

Practically, for the next three weeks:

If you hold CPT licences, you have the cost data CMS asked for in question 1. Very few commenters will. Licence acquisition and maintenance costs, per-seat fees, and the effect on downstream tooling are exactly what CMS said it wants cited.

If you run a laboratory or imaging service, the duplicate-testing RFI is the one with teeth. MAC edits and payment-integrity recoupment do not need new legislation, and the vitamin D LCD shows the mechanism already works. The exceptions you want preserved need to be named now, with clinical justification, or they will be argued for by someone else.

Comment under the right file code. Both RFIs are within CMS-1848-P, docket CMS-2026-2377, with a single deadline of 14 September 2026.

Frequently asked questions

Is CMS proposing to stop using CPT codes?

No. This is a request for information. CMS proposed no change to 45 CFR 162.1002(a)(5) and made no commitment to future rulemaking. Question 3 asks what alternatives would exist if CMS revisited the standard.

Could CMS actually replace CPT without Congress?

The RFI’s own reasoning is that the CPT requirement comes from an HHS regulation implementing HIPAA rather than from the HIPAA statute, which does not mention CPT. That would make it amendable through notice-and-comment rulemaking. Whether that is legally straightforward is a separate question the RFI does not answer, and no proposal exists to test it.

What are the CY 2027 conversion factors going to be?

Not yet determined. The proposed rule projects decreases of $0.40 (−1.19 percent) from $33.4009 for the qualifying APM conversion factor and $0.56 (−1.68 percent) from $33.5875 for the nonqualifying one. Final figures come in the final rule.

Are frequency limits on laboratory tests being imposed by this rule?

No. CMS listed frequency limitations as one of four mechanisms it is exploring and asked which tests should be subject to them and what exceptions are needed. Existing frequency limits, such as LCD L33996 for vitamin D assay testing, are already in force independently of this rule.

When do comments close, and where do they go?

14 September 2026. Electronically at regulations.gov under docket CMS-2026-2377, or by mail to CMS marked with file code CMS-1848-P. Late comments are not assured consideration.

Primary source: Centers for Medicare & Medicaid Services, “Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program,” 91 FR 43842 (16 July 2026), file code CMS-1848-P, RIN 0938-AV82, docket CMS-2026-2377, comments due 14 September 2026. Cited within the rule: 45 CFR 162.1002(a)(5); section 1848(d)(1)(A) of the Social Security Act; MedPAC testimony, “Options to Improve Medicare’s Payments to Physicians,” 8 May 2007; National Academies of Sciences, Engineering, and Medicine, “Improving Primary Care Valuation Processes to Inform the Physician Fee Schedule” (2025); LCD L33996; section 4003 of the 21st Century Cures Act, Pub. L. 114-255.