You know the version of this that happens in your own shop. A study exists. It is good. It is eleven days old, it is sitting on a PACS four miles away, and the ordering physician cannot see it, cannot get a login, cannot wait, and re-orders. Somebody scans the patient again. Everyone involved behaves reasonably and the program pays twice.
CMS has been circling that for years in the language of interoperability. On July 16 it wrote something different into the proposed 2027 Physician Fee Schedule — a request for information, section X, starting on page 44139 of a 716-page rule. No code changes. No regulatory text. Which is precisely why it will not appear in anyone's summary of the fee schedule, and why it is the part of that rule I would read first.
Start with the menu. CMS lists what it is exploring.
Given the concerns discussed previously in this section resulting from duplicate diagnostic laboratory and image testing, we are exploring various mechanisms for addressing duplicative payment: Clarifications to billing instructions to laboratories and imaging centers on parameters of duplicate laboratory or imaging tests; Local Medicare Administrative Contractor (MAC) edits that would result in non-payment or reductions in payment as applicable for duplicate laboratory or imaging tests; Use of payment integrity levers to recoup payments from health care providers and suppliers who performed duplicate laboratory or imaging tests; and Application of frequency limitations to certain tests where clinically appropriate.
Read the verbs. A MAC edit does not pay. A payment-integrity lever recoups money already paid. A frequency limitation refuses the claim on the calendar. Three of the four operate on the entity that performed the study — and performing it is the one thing an imaging provider does not get to decide. The order arrives. You scan.
Then CMS asks the question that actually has teeth, and it asks it about a provider who did nothing wrong at all.
How should CMS account for cases in which repeat imaging occurs because prior imaging results were not available for timely, standards-based reuse? Should CMS consider payment, quality, or participation policies that create accountability for the initial imaging provider, furnishing entity, or facility when failure to make results reusable contributes to avoidable repeat imaging? Are there penalties or disincentives for non-compliance we should consider?
The initial imaging provider. Not the one who ordered the repeat. Not the health system whose PACS has no outward-facing door. The practice that did the first study correctly, released the report, and could not make the pixels reusable by somebody it has never had a contract with.
I do not think that is a gotcha. I think CMS is looking for the party it can actually reach through a payment system, and the performing provider is the party a payment system can reach. That is the whole problem with using payment as a lever for an interoperability failure: the money moves through the one participant who has the least control over the failure.
An RFI is the cheapest thing in a proposed rule to ignore and the most expensive to have ignored, because the design happens before anyone gets to argue about the numbers.
Further down, CMS asks whether it should set a floor for what a shareable result even is — and attaches it to payment: whether to require “all participating entities to deliver both a structured Fast Healthcare Interoperability Resources (FHIR) R4 Diagnostic Report resource and a human-readable Portable Document Format/Archive (PDF/A) rendition to the ordering health care provider's designated endpoint as a condition of Medicare payment.” It then asks, in the same breath, “How should CMS address health care providers who have not yet implemented FHIR-native workflows, especially in rural areas?” That is a question about whether a rural imaging center's Medicare payment can turn on the shape of its outbound data. And the backdrop CMS describes for all of it, quoting responses to an earlier RFI, is an exchange environment with “ongoing dependence on CDs and DVDs.”
Comments on the CY 2027 Physician Fee Schedule proposed rule, file code CMS-1848-P, are due September 14, 2026. That single date governs the whole 716-page document, so the fee-schedule sections and this RFI share a deadline — and the fee-schedule sections are what will consume everyone's attention between now and then. There is no separate comment period for the interoperability questions, and CMS has not committed to a proposed rule on them at all.
Kept honest: nothing in this section changes payment today, and nothing in it is a proposal. A request for information asks questions; it contains no regulatory text, CMS is not bound to act on it, and it may produce nothing. The four mechanisms are quoted as CMS's own list of what it is “exploring,” not as anything scheduled. Two honest counterweights sit in the same section: CMS frames the underlying harm as patient harm — incomplete care, delay, and in imaging specifically “unnecessary radiation exposure” — and it explicitly walked back the biggest hammer it considered, noting that it thought about requiring hospitals to join a national interoperability network through the Electronic Notifications Condition of Participation, then observed that the only statutory penalty for a hospital CoP violation is termination from Medicare and said it “would be overly burdensome.” Read that as an agency looking for a proportionate lever rather than an agency looking for someone to punish. The reading that three of the four listed mechanisms fall on the performing provider is mine, from the text of the list; CMS does not characterize them that way. Everything quoted here is from the Federal Register text of the proposed rule as published; the specialty-level impact tables in the same document are published as images and are not quoted here at all.
Sources (primary, verified today): Centers for Medicare & Medicaid Services, HHS, “Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule…,” proposed rule, 91 FR 43842 (July 16, 2026), file code CMS-1848-P — every quotation is from section X, “Request for Information (RFI) on Duplicate Laboratory Testing, Imaging, and Result Sharing and Interoperability,” at 91 FR 44139–44141. federalregister.gov serves its full-text file behind a block, so the text was read from the govinfo HTML of the same document; the comment deadline, docket and page range were confirmed against the Federal Register JSON API record. The earlier ONC RFI referenced inside the section is cited by CMS as 91 FR 4054 (January 30, 2026). No trade coverage supplied any fact in this edition.
Buried on page 44139 of the 716-page proposed 2027 Medicare Physician Fee Schedule is a request for information about duplicate imaging and lab tests. No code changes. No regulatory text. It will not make anyone's summary of the rule. It contains the most consequential question CMS has asked radiology in a while. First, the menu. CMS says it is "exploring various mechanisms for addressing duplicative payment": - clarifications to billing instructions to laboratories and imaging centers - "Local Medicare Administrative Contractor (MAC) edits that would result in non-payment or reductions in payment" - "Use of payment integrity levers to recoup payments from health care providers and suppliers who performed duplicate laboratory or imaging tests" - "Application of frequency limitations to certain tests where clinically appropriate" Read the verbs. An edit doesn't pay. A payment-integrity lever takes money back. A frequency limit refuses the claim on the calendar. Three of the four operate on whoever PERFORMED the study. Then, two pages later, the question with actual teeth: "How should CMS account for cases in which repeat imaging occurs because prior imaging results were not available for timely, standards-based reuse? Should CMS consider payment, quality, or participation policies that create accountability for the INITIAL imaging provider, furnishing entity, or facility when failure to make results reusable contributes to avoidable repeat imaging? Are there penalties or disincentives for non-compliance we should consider?" The initial imaging provider. Not the physician who ordered the repeat. The practice that did the first study correctly, released the report, and couldn't make the images reusable by someone it has no relationship with. I don't read that as a gotcha. I read it as an agency looking for the party it can reach through a payment system — and the performing provider is the party a payment system can reach. That's the structural problem with using payment as the lever for an interoperability failure. The money runs through the participant with the least control over it. There's a second question in the same section with a dollar sign on it: whether to require every participating entity to deliver a structured FHIR R4 Diagnostic Report AND a human-readable PDF/A to the ordering provider's endpoint "as a condition of Medicare payment." Followed immediately by: "How should CMS address health care providers who have not yet implemented FHIR-native workflows, especially in rural areas?" The backdrop CMS describes, quoting responses to an earlier RFI: an imaging exchange environment with "ongoing dependence on CDs and DVDs." To be fair to CMS, the framing isn't punitive. It names the harm as patient harm — delayed care and, for imaging, "unnecessary radiation exposure." It also considered requiring hospitals to join a national interoperability network through the Conditions of Participation and backed off, because the only statutory penalty for a CoP violation is termination from Medicare, which it said "would be overly burdensome." That's an agency hunting for a proportionate lever, not a scalp. But proportionate levers get designed at the RFI stage, not at the proposal stage. Two things worth doing before September 14, when comments on CMS-1848-P close: 1. Find out what your outbound looks like to a stranger. Not to a referrer with a portal login — to an unaffiliated physician holding your patient. Report and images, standard format, no phone call. "Timely, standards-based reuse" is the phrase everything in this RFI hangs off. 2. Count your own repeats. Same patient, same body part, inside 30 days, split into clinically indicated versus "a prior existed and nobody could get it." Nobody outside your practice has that number. It is the single most useful thing you could put into this record. The comment window on an RFI is the design window. After it closes, you're arguing about a mechanism instead of about whether it should exist. Source: 91 FR 43842, section X at 44139–44141, July 16, 2026 (CMS-1848-P). Read from the govinfo text of the rule. Nothing here changes payment today — an RFI proposes nothing, and CMS is not obligated to act on it.
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FIRST SOURCE · one verified original-source finding, composed for one reader · this edition: radiology — written for the consultants, practice coalitions and imaging groups whose clients will hear about the fee schedule and never hear about page 44139