Posted in: Government Outreach
September 12, 2025
Dr. Mehmet Oz
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1828-P
P.O. Box 8013
Baltimore, MD 21244-8013
RE: CMS-1832-P
Submitted via: https://www.regulations.gov
Dear Dr. Oz,
The Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) appreciates the opportunity to submit comment to the Centers for Medicare & Medicaid Services (CMS) regarding the recently proposed rule entitled Medicare and Medicaid Programs; CY 2026 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.
AAAHC is a private and independent 501(c)(3) non-profit accrediting organization formed in 1979. Since its inception, AAAHC has promoted a voluntary, peer-based, and educational survey process to advance patient care. These values hold true today, as embodied in our mission statement: Improving health care quality through accreditation. With more than 6,700 accredited organizations in a variety of ambulatory health care settings, AAAHC is a leader in developing Standards to advance and promote patient safety, quality care, and value for ambulatory health care through its accreditation programs, education, research, and other resources. Currently, more than 1,000 ASCs are committed to excellence through AAAHC accreditation under the deemed status program, making AAAHC the leading Medicare-deemed ambulatory surgical center accrediting organization in the country.
AAAHC also provides accreditation services to the United States Coast Guard (USCG) ambulatory health centers, Federally Qualified Health Centers (FQHCs) that receive funds from the United States Health Resources and Services Administration (HRSA), and Indian Health Services (IHS) funded health centers. Other AAAHC-accredited organizations include Community Health Centers, Student Health Centers, Medical Group Practices, and office-based surgery procedure centers.
As one of four accreditation organizations granted deeming authority for ambulatory surgical centers (ASCs), AAAHC has a significant interest in providing thoughtful and meaningful commentary to the agency in support of a continuing effective relationship. The following includes AAAHC comments, recommendations, and positions as a partner to CMS with the shared goal of improving the quality of health care, and in support of federal government initiatives to increase access to health care services, reduce burden, and provide for consistency across similar programs.
Note: For ease of reading, this comment lists the specific sections to which AAAHC is responding. Any sections for which AAAHC does not provide comment should not be interpreted to mean that AAAHC supports or opposes the proposal.
II. Provisions of the Proposed Rule for the PFS
B. Determination of PE RVUs
5. Development of Strategies for Updates to Practice Expense Data Collection and Methodology
c. Updates to Practice Expense (PE) Methodology—Site of Service Payment Differential
In this section, CMS proposes to reduce the portion of the facility PE RVUs allocated based on work RVUs to half the amount allocated to non-facility PE RVUs and requests comments on whether this is an appropriate reduction or whether we should consider a different percentage reduction for CY 2026 or in future years.
AAAHC acknowledges CMS’s data showing a significant decline in physician-owned practices and a corresponding rise in hospital or corporate entity ownership. This trend raises significant concerns about access to care, particularly in rural and underserved communities where independent practices have historically played a critical role in serving vital healthcare access points.
AAAHC cautions that corporate entities may close acquired practices that fail to meet revenue targets, leaving patients with fewer care options. The proposed reduction in reimbursement could further discourage physicians from maintaining independent practices, exacerbating access challenges.
In alignment with CMS’s commitment to person-centered care, AAAHC recommends that, rather than reducing reimbursement, the federal government consider offering greater incentives to support and sustain independent physician practices, especially in areas where they are essential to community health.
6. Payment for Services in Urgent Care Centers
CMS seeks comments regarding whether separate coding and payment are needed for evaluation and management visits furnished at urgent care centers, including whether an add-on code would be appropriate or if a new set of visit codes would be more practical.
As CMS evaluates potential expansion of Medicare reimbursement to urgent care centers, it is important to recognize that state-based oversight requirements vary significantly and do not uniformly mandate physician supervision or quality standards. The lack of a standardized definition of “urgent care” at the federal level complicates efforts to ensure consistent care, quality, and safety. To promote uniformity and accountability, CMS should establish federal minimum standards—such as Conditions for Coverage (CfCs) or Conditions of Participation (CoPs)—like those used for other provider types.
These standards should include requirements for medical oversight, emergency protocols, infection control, and continuity of care. To streamline implementation, CMS could establish a deeming pathway through nationally recognized accreditation bodies, such as AAAHC, whose Standards emphasize patient-centered care, data-driven quality improvement, and alignment with state regulations. This approach would support diverse care models while ensuring safety and consistency across urgent care settings.
D. Payment for Medicare Telehealth Services Under Section 1834(m) of the Act
1. Payment for Medicare Telehealth Services Under Section 1834(m) of the Act
AAAHC supports CMS’s proposal to revise the Medicare Telehealth Services List review process beginning in CY 2026 by keeping Steps 1 through 3 and removing Steps 4 and 5, which have created confusion and administrative burden. We agree that physicians and other practitioners should lead discussions about the clinical appropriateness and safety of telehealth services, as they are best positioned to evaluate individual patient needs. To ensure quality, governing bodies should require organizations to have frameworks that support physician-led decision-making.
AAAHC’s accreditation standards already promote this approach. Our Standards require organizations to define the scope of services provided and the patient population they serve, ensuring that clinical decisions reflect patient acuity, safety, and service complexity. AAAHC developed these Standards through a rigorous evidence-based process and regularly updates them to align with CMS and other regulatory requirements. AAAHC-accredited organizations must demonstrate continuous quality improvement, maintain comprehensive documentation of clinical decisions, and prioritize patient safety and outcomes.
We commend CMS for recognizing the importance of clinical judgment and encourage continued reliance on nationally recognized accreditation standards, such as those developed by AAAHC, to guide safe and effective telehealth delivery. This approach will help ensure access, safety, and quality of care while reducing unnecessary regulatory complexity.
2. Other Non-Face-to-Face Services Involving Communications Technology Under the PFS
a. Direct Supervision via Use of Two-Way Audio/Video Communications Technology
AAAHC supports CMS’s proposal to permanently define direct supervision to include “immediate availability” through real-time audio/video communications technology (excluding audio-only) for services under § 410.26, excluding those with 010 or 090 global surgery indicators. This update modernizes supervision standards and aligns with AAAHC’s accreditation framework, which emphasizes physician-led clinical judgment and patient-centered care when appropriate safeguards are in place. AAAHC standards require organizations to maintain written policies ensuring that a qualified physician or delegated health care professional is present until the patient is medically discharged following recovery from surgery or anesthesia. We also require post-operative evaluations to assess recovery and determine follow-up care, even for procedures with a 000 global surgery indicator.
However, we urge CMS to consider the limitations faced by remote and rural facilities, where reliable broadband may not support consistent, high-quality audio/video communication. In these areas, virtual supervision may not be feasible and requiring it could inadvertently reduce access to care or compromise patient safety. We recommend that CMS allow flexibility for facilities in low-connectivity regions to meet supervision requirements through alternative means, provided they maintain rigorous quality and safety standards.
AAAHC appreciates CMS’s recognition of clinical judgment and encourages continued reliance on nationally recognized accreditation standards, such as those developed by AAAHC, to guide safe and effective supervision. This approach balances flexibility with patient safety and supports broader access to care in diverse practice settings.
b. Proposed Changes to Teaching Physicians’ Billing for Services Involving Residents With Virtual Presence
AAAHC supports CMS’s proposal to extend the policy allowing teaching physicians to be virtually present via real-time audio/video communications technology (excluding audio-only) for purposes of billing when services involving residents are furnished virtually, such as during a three-way telehealth visit. This policy appropriately reflects the evolving nature of care delivery and supports continuity of education and supervision in a virtual environment. AAAHC agrees that this flexibility is appropriate, provided that clinical documentation clearly indicates the teaching physician’s presence—whether physical or virtual—and specifies the portion of the services they supervised. This documentation requirement aligns with AAAHC’s accreditation requirements, which emphasize transparency, accountability, and quality assurance in clinical supervision.
G. Enhanced Care Management
1. Integrating Behavioral Health Into Advanced Primary Care Management (APCM)
AAAHC strongly supports CMS’s proposal to integrate behavioral health into Advanced Primary Care Management (APCM), recognizing the critical link between behavioral health and chronic disease outcomes. AAAHC accreditation standards emphasize integrated, team-based care models that promote bidirectional coordination between behavioral health and primary care. This integration is essential across all care settings and is foundational to improving patient experience, reducing depression severity, and enhancing chronic disease management.
We also support CMS’s proposal to introduce optional add-on codes for APCM services that eliminate time-based documentation requirements for Behavioral Health Integration (BHI) and Collaborative Care Model (CoCM) services. Reducing documentation burden will encourage broader adoption and enable more holistic care delivery. AAAHC Standards already require organizations to maintain policies that support coordinated care, appropriate supervision, and documentation of clinical decision-making, aligning with the goals of this proposal.
Additionally, AAAHC recommends that CMS include preventive services, such as the Annual Wellness Visit, depression screening, and other screenings in the APCM bundle. Bundling these services will reduce cost-related barriers and improve uptake, particularly among patients who may decline services due to out-of-pocket costs or lack of price transparency.
I. Policies To Improve Care for Chronic Illness and Behavioral Health Needs
1. Updates to Payment for Digital Mental Health Treatment (DMHT) and Comment Solicitation on Payment Policy for Software as a Service (SaaS)
b. Comment Solicitation on Payment Policy for Software as a Service (SaaS)
AAAHC appreciates CMS’s solicitation of feedback on how to appropriately value and reimburse Software as a Service (SaaS) and AI technologies under the Physician Fee Schedule. As CMS considers alternative pricing strategies, we recommend grounding any payment model in quality standards established by nationally recognized accreditation organizations.
We support CMS’s consideration of methodologies such as aligning with OPPS geometric mean costs or cross walking from OPPS technical components as interim strategies. However, we also encourage CMS to develop models that reflect the longitudinal value of SaaS tools in improving outcomes and reducing unnecessary utilization.
SaaS technologies offer significant potential to enhance outpatient care by streamlining clinical and administrative workflows. These tools can improve scheduling, provide real-time access to clinical data, support procurement and cost analysis, verify insurance eligibility, and automate reminders. Additionally, SaaS can generate diagnostic summaries and wellness visit insights that inform or even mitigate the need for certain services. These efficiencies improve the patient experience and promote better resource use and care coordination.
However, integrating SaaS and AI technologies requires a strong governance framework to ensure ethical and responsible use. This includes obtaining patient consent for data use, maintaining transparency in AI-driven decisions, and addressing risks related to bias and discrimination. Because many AI tools operate as “black boxes,” clinicians and patients may struggle to understand the rationale behind certain recommendations.
AAAHC expects accredited organizations to implement robust governance structures and risk mitigation strategies when adopting modern technologies. Our Standards require training for physicians and other practitioners on the use of technology, emphasize clinical judgment in interpreting outputs, and prioritize patient safety and privacy. AAAHC’s Standards highlight the importance of data integrity, clinical oversight, and continuous quality improvement. We also require organizations to implement policies that ensure appropriate use, documentation, and evaluation of digital tools, especially those that support clinical decision-making and chronic disease management.
To ensure safe and equitable use of SaaS technologies, CMS should evaluate whether existing standards, such as those from NIST and other regulatory bodies, adequately address interoperability, accountability, privacy, and safety in clinical settings.
2. Prevention and Management of Chronic Disease—Request for Information
AAAHC welcomes CMS’s broad request for feedback to strengthen prevention and management of chronic disease. We strongly recommend that CMS require practitioners to adhere to nationally recognized quality standards, such as those outlined in AAAHC’s Ambulatory Accreditation with Medical Home recognition. These standards emphasize communication in a manner the patient understands, care coordination, continuity of care, patient follow-up, documentation, and appropriate referrals—core elements of effective chronic disease management.
We support the development of separate coding and payment mechanisms for services that address root causes of chronic disease, including intensive lifestyle interventions, medically tailored meals, and FDA-cleared digital therapeutics. These services often demand significant time and resources that the current Physician Fee Schedule (PFS) does not adequately capture. For example, medically tailored meals delivered under general supervision could be supported through partnerships with community-based organizations, as long as a supervising practitioner maintains oversight. AAAHC Standards already require organizations to inform patients about their condition, including preventive care, and to have policies in place for post-discharge care planning and coordination structures that can support these expanded services.
The AAAHC Standards also include a Behavioral Health Category that outlines the expectations for interventions designed to improve and enhance the emotional, mental, and behavioral health of patients, and AAAHC has a variety of stakeholders on our committees and even our Board of Directors, with expertise in the methods of care that support chronic care through behavioral health methods. AAAHC appreciates the opportunity to provide feedback regarding motivational interviewing and health coaches, including the potential development of separate coding and payment for motivational interviewing (MI) and health coaching services. Motivational interviewing is a collaborative, goal-oriented communication method that supports patient-centered care by helping individuals explore and resolve ambivalence toward behavior change. Existing codes such as SBIRT for substance use, tobacco cessation, and obesity counseling, reflect MI principles only in condition-specific contexts. Given the broad applicability of MI across chronic disease prevention and management, separate coding and payment would better reflect the time, training, and resources required to deliver this service effectively.
Health coaches often incorporate motivational interviewing techniques as part of their broader approach to patient engagement. While MI is a distinct methodology, it is frequently used by health coaches to collaboratively develop goals and action plans with patients. In this context, health coaches serve as adjuncts to providers, who should establish the clinical framework using MI principles. Health coaching encompasses a wider range of strategies, with MI being an effective tool for facilitating behavior change. To ensure quality and consistency, practitioners delivering MI should receive formal training that emphasizes the purpose and philosophy of the method—namely, fostering autonomy, empathy, and collaboration to support sustainable health behavior change.
General supervision provisions for behavioral health services furnished by auxiliary personnel, like § 410.26(a)(3), could allow trained health coaches to deliver MI incident to a billing practitioner. This would expand access and integrate health coaches more fully into care teams. MI and health coaching may be used more often in primary care settings where behavior change is essential, including to address risky alcohol consumption, hypertension, diabetes management, tobacco and substance use, and lifestyle factors such as diet, exercise, sleep, and stress. MI can also be useful in surgical settings to motivate self-care and adherence to physical therapy and other discharge protocols. MI is particularly appropriate when patient ambivalence or low motivation is a barrier to improved health outcomes. Both MI and health coaching can be effectively delivered via audiovisual or audio-only synchronous telecommunication, making them well-suited for telehealth expansion.
Creating permanent codes with general supervision provisions would establish a clearer payment pathway, recognize health coaching as part of chronic care, and reimburse valuable care-management work that is often unbilled.
From an accreditation perspective, the Accreditation Association for Ambulatory Health Care Standards emphasize patient-centered care, continuity of care, and the use of evidence-based practices. MI aligns closely with these standards by promoting individualized care planning, shared decision-making, and improved patient engagement. Incorporating MI into routine practice supports AAAHC’s focus on quality improvement and patient outcomes, and formal recognition through coding and payment would further reinforce its value in all care settings. With proper oversight, motivational interviewing can be a patient-centered approach that supports chronic disease prevention and management.
4. Technical Refinements To Revise Terminology for Services Related to Upstream Drivers of Health
a. Policies To Improve Care for Chronic Illness and Behavioral Health Needs
(1) Social Determinants of Health Risk Assessment (HCPCS Code G0136)
(2) Community Health Integration Services (HCPCS Codes G0019)
AAAHC supports CMS’s proposed updates to HCPCS code G0019 and related codes to promote a more person-centered, comprehensive approach to Community Health Integration (CHI) services. We commend CMS for shifting terminology from “Social Determinants of Health (SDOH)” to “Upstream Drivers,” which better captures the broader systemic and contextual factors that influence health outcomes.
AAAHC’s Patient-Centered Medical Home (PCMH) certification and Ambulatory Accreditation with Medical Home recognition emphasize the importance of person-centered assessments, care coordination, and continuity of care—core elements of the proposed CHI service structure. Our Standards require organizations to implement policies that support individualized care planning, cultural and linguistic responsiveness, and coordination across medical, behavioral, and community-based services. These Standards align closely with the proposed CHI service components, including patient-driven goal setting, health system navigation, and building self-advocacy skills. We also support the emphasis on leveraging lived experience and providing social and emotional support, which are consistent with AAAHC’s commitment to whole-person care.
To ensure consistent quality across care settings, we recommend that CMS continue to align CHI service requirements with nationally recognized accreditation standards. This alignment will help ensure that auxiliary personnel delivering CHI services receive appropriate training and supervision, and that care coordination efforts are documented and integrated into the broader treatment plan.
J. Provisions on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Other Covered Services
1. Medicare Payment for Dental Services
AAAHC is disappointed that CMS has not prioritized dental services as a focus area within chronic care management for CY 2026, despite ongoing public engagement and submissions highlighting their importance. Oral health is inextricably linked to overall health, particularly in the management of chronic conditions such as diabetes, cardiovascular disease, and respiratory illness. AAAHC Standards recognize the role of integrated, whole-person care—including dental services—as essential to improving outcomes and reducing long-term costs.
We urge CMS to revisit this issue and consider proposals that support the inclusion of dental services in chronic care models, especially where they directly impact the diagnosis, treatment, and management of chronic disease. AAAHC Standards promote coordinated care across disciplines, including dental, medical, and behavioral health, and require organizations to implement policies that support comprehensive care planning and follow-up. We also request that CMS continue to engage with stakeholders and prioritize dental services in future rulemaking to ensure equitable access and improved health outcomes for Medicare beneficiaries.
IV. Updates to the Quality Payment Program
AAAHC is concerned about CMS’s proposal to remove IA_PCMH—electronic submission of Patient-Centered Medical Home accreditation—from newly proposed and finalized MVP tables. While we appreciate that clinicians may still attest to this activity under § 414.1380(b)(3)(ii), we strongly recommend that CMS continue to list PCMH accreditation explicitly in MVP tables to reinforce its value and visibility.
AAAHC’s PCMH certification and Ambulatory Accreditation with Medical Home recognition support integrated, team-based care models that include behavioral health coordination, chronic disease management, and upstream interventions. These standards directly align with the goals of ASM and other Innovation Center models, such as the Integrated Patient-Centered Behavioral Health (IBH) Model. PCMH accreditation offers a proven framework for improving outcomes, enhancing patient experience, and reducing unnecessary utilization—especially for solo and small practices that CMS aims to support through ASM.
We urge CMS to continue recognizing PCMH accreditation as a meaningful improvement activity and to include it in future MVPs and care models. Doing so will help ensure that practices committed to person-centered, coordinated care are appropriately acknowledged and incentivized.
Thank you again for the opportunity to comment on these significant proposals. For any questions regarding this comment, please contact Ann Carrera, Senior Counsel, Legal & Corporate Affairs, at 847-853-6060 or acarrera@aaahc.org.
Sincerely,
Noel M. Adachi, MBA
President & CEO
