Medicare Pays Twice for Single-Visit Procedures, Costing Patients and Taxpayers

A structural billing feature in Medicare's fee schedule allows separate reimbursement for evaluation and same-day procedures, raising questions about program efficiency that Congress has not yet...

Medicare routinely pays two separate charges when a physician both evaluates and treats a patient during a single office visit, a billing pattern that affects millions of beneficiaries annually and adds costs to both the federal program and individual patients through coinsurance obligations.

Under Medicare's fee schedule, an evaluation and management (E&M) code and a procedure code can each be billed and reimbursed at close to full price during the same appointment. A patient visiting a dermatologist who receives both a mole examination and same-day removal may owe coinsurance on two separate line items, according to an analysis published September 24, 2026, by the Washington Examiner.

The Centers for Medicare and Medicaid Services (CMS) governs the physician fee schedule under authority granted by Congress in the Balanced Budget Act of 1997 and subsequent legislation. CMS publishes the fee schedule annually in the Federal Register. The specific billing rules permitting simultaneous E&M and procedure reimbursement are codified in the agency's National Correct Coding Initiative (NCCI) edits, which define when two codes may or may not be billed together.

When two services are billed together and not blocked by an NCCI edit, Medicare pays both claims. The patient is responsible for 20 percent coinsurance on each allowed amount, absent supplemental coverage. For a beneficiary without Medigap insurance, a single visit with two billable codes can generate two separate out-of-pocket obligations.

The practice is not limited to dermatology. CMS data show that same-day E&M and procedure billing occurs across ophthalmology, gastroenterology, urology, and other specialties. The precise annual dollar value attributable specifically to same-day dual billing is not publicly broken out in a single CMS report. The document that would contain specialty-level billing frequency data is the CMS Physician and Other Supplier Public Use File, available at data.cms.gov.

Congress has periodically examined Medicare payment accuracy. The Medicare Payment Advisory Commission (MedPAC), an independent congressional advisory body, publishes annual reports to Congress assessing payment adequacy and program efficiency. MedPAC's March 2026 Report to Congress did not include a dedicated chapter on same-day E&M and procedure billing combinations, according to the publicly posted table of contents on medpac.gov.

The Government Accountability Office (GAO) has issued multiple reports on Medicare billing integrity. GAO-22-104321, published in 2022, examined Medicare payment vulnerabilities broadly but did not focus specifically on same-day evaluation and procedure billing as a distinct category. No current GAO engagement on this specific billing pattern appears in the GAO's open recommendations database as of the publication date of this article.

No legislation introduced in the 119th Congress as of September 24, 2026, specifically addresses the elimination of same-day E&M and procedure dual billing, according to a search of Congress.gov using the terms "evaluation and management" and "same-day procedure." The absence of a bill does not preclude CMS from acting through rulemaking, as the agency has the authority to modify NCCI edits administratively.

Physician and hospital groups, including the American Medical Association (AMA), have historically opposed reductions to E&M reimbursement and have lobbied against bundling policies they argue undervalue physician cognitive work. AMA lobbying disclosures filed with the Senate Office of Public Records show the organization spent $24.26 million on federal lobbying in 2025, covering issues including Medicare physician payment. The specific positions taken by the AMA on same-day billing bundling are detailed in the organization's public comment letters to CMS, which are posted in the Federal Register docket for each annual physician fee schedule rulemaking.

For beneficiaries, the financial exposure from dual coinsurance obligations depends on whether they hold supplemental Medigap coverage, are enrolled in a Medicare Advantage plan with different cost-sharing rules, or are in traditional fee-for-service Medicare with no secondary insurance. CMS enrollment data for 2025 show approximately 34.5 million beneficiaries in traditional Medicare, the population most directly subject to the fee-for-service billing structure described above.

What remains unknown is the total annual Medicare expenditure and beneficiary coinsurance burden attributable specifically to same-day E&M and procedure billing pairs. That figure could be calculated from the CMS Medicare Fee-for-Service Claims Data file, which is available to qualified researchers through the CMS Virtual Research Data Center but is not published in aggregated form by billing-pair combination.