LinkedIn Live Recap: CMS Questions the AMA’s Billing Code ‘Monopoly.’ Comment by 9/14

For the first time in decades, the federal government is openly questioning who should control the billing codes that decide what counts, and what gets paid, in American healthcare. And nurses have only days left to weigh in.

That was the message of a LinkedIn Live conversation held yesterday, September 9, hosted by Rebecca Love, RN, MSN, FIEL, co-chair of the Center of Nursing Value, featuring two of the most prominent nurse voices in health policy: Betty Rambur, PhD, RN, FAAN, professor and Routhier Chair for Practice at the University of Rhode Island College of Nursing and vice chair of the Medicare Payment Advisory Commission (MedPAC), and Stephanie Witwer, PhD, RN, a strategic consultant for the American Academy of Ambulatory Care Nursing (AAACN) Center for Innovation and Excellence and a national leader in ambulatory care nursing.

The LinkedIn Live covered the proposed 2027 Medicare Physician Fee Schedule, which is open for public comment through September 14, 2026. In the proposed rule, CMS asks stakeholders directly whether it should keep relying on the American Medical Association’s CPT codes and the AMA’s Relative Value Scale Update Committee (RUC), using the word “monopoly” to describe the AMA’s control of the system.

Watch the full conversation below, and read on for the highlights and how to submit a comment before the deadline.

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“The conversation today is going to focus on the issue that the AMA, because of their ownership of CPT codes, decides what counts for reimbursement,” Rambur said. “And then the AMA specialty dominated group, the RUC, sets the prices for those services.”

CPT codes are the standardized terms used to report and bill medical services. They sit inside the larger HCPCS coding system that CMS maintains, and they are the largest part of it, with more than 11,000 codes and more added every year. The codes are wholly owned and trademarked by the AMA, which earns revenue every time they are licensed and used.

Witwer explained that while the AMA’s stated purpose is to provide codes for physicians and other qualified health providers, in practice the CPT process has become the gatekeeper for every discipline. Physical therapists, occupational therapists, dietitians, respiratory therapists, mental health providers, and others have obtained CPT codes through the AMA’s process. Registered nurses have not.

“There’s no CPT codes that have specifically been designed for RN delivered services,” Witwer said.

She pointed to code 99211, one of the most commonly used codes in ambulatory nursing practice. “The same code is used for a quick, a ten minute blood pressure recheck and a forty five minute complex education visit for a newly diagnosed diabetic patient,” she said. The value generated flows to the supervising physician or qualified health provider, not to the nurse who did the work.

The consequences run through the entire payment system. Relative value units (RVUs) assign a dollar value to each CPT code based on the work of the physician or qualified health provider, practice expense, and malpractice expense. Registered nurses fall under practice expense, alongside supplies and overhead.

“Payment is the currency of value,” Witwer said. Practices maximize what is reimbursable and minimize what is treated as expense, “including registered nurses who are providing services.”

Rambur called it “the visible problem of the invisible profession.”

“I’m very concerned about the invisibility of us, the visible problem of the invisible profession, because so much of what people need is nursing care.” – Betty Rambur, PhD, RN, FAAN

CMS is not required to accept the AMA’s code values, but Rambur noted that it has historically adopted RUC recommendations about 90 percent of the time, making the process nearly a one-to-one pass-through from a private organization into federal payment policy.

Both guests placed the comment period against a stark economic backdrop. Rambur cited figures showing the national debt reaching $40 trillion, roughly $117,000 for every person in the United States, with healthcare costs the fastest growing contributor. She cited estimates that a quarter to a third of the roughly $5.2 trillion the nation spends on healthcare each year is waste or low-value care, driven in large part by what the payment system does and does not pay for.

“To me, the way you do it is by changing what you pay for and get rid of waste and low value care,” Rambur said.

The proposed rule asks for evidence of harms associated with what CMS itself calls the AMA’s “monopoly over CPT IV licenses,” whether competing coding systems should be permitted, and what objective alternatives could replace the current CPT and RUC process. Rambur pointed to longstanding concern, quoted in the rule, about federal reliance on a private organization with a conflict of interest in valuing the very services its members bill.

“I think about how different it would be if nurses would have set the codes for what gets to matter for payment.” – Betty Rambur, PhD, RN, FAAN

Rambur said an independent valuation process is overdue. “It needs to be an independent group whose responsibility is to taxpayers, to patients,” she said, noting a bill sponsored by Senators Cassidy and Whitehouse that proposes an objective alternative to the RUC process for primary care.

The same proposed fee schedule cycle includes something new: AMA-proposed CPT codes for artificial intelligence, in three categories:

• Assistive codes detect clinically relevant information for a physician or qualified health provider to act on.
• Augmentative codes analyze and quantify data into recommendations.
• Autonomous codes would interpret data and generate clinically meaningful decisions without physician action unless a clinician intervenes.

Rambur warned that unbundling AI for separate reimbursement will likely increase costs, and questioned whether it duplicates payment that already exists. She noted that medical decision-making already accounts for 52 percent of the work value in the CPT structure. “Are we not creating a redundant reimbursement system if we reimburse AI separately on top of the CPT code that’s already reimbursing for medical decision making?” she asked.

The panel also confronted the workforce question head-on: if a nurse is booked as a cost and an AI tool becomes revenue-generating, will organizations cut nurses to buy tools?

“I think that is not determined yet how that will happen. I think that actually could happen,” Rambur said, while noting the limits of automation. “I can’t imagine that AI can easily take the place of a hospice nurse.”

“So much of what nursing does is around care, not cure.” – Betty Rambur, PhD, RN, FAAN

Witwer raised a different risk: nurses becoming the unpaid safety net for autonomous AI. “Is it going to fall to the nurse to really determine whether or not that order is safe?” she asked. “When an error is made, and it will be, who’s accountable?”

The public comment period on the proposed 2027 Physician Fee Schedule closes September 14, 2026. Love said more than 32,000 comments had already been submitted as of the recording, and stressed that comments become part of the formal record that can shape future rulemaking and litigation. There is no limit on the number of comments one person can submit.

Witwer urged nurses not to be intimidated by the scale of the questions. “If you can’t figure out what the alternative to the CPT code system is, think about what you can comment on,” she said, pointing to individual codes, like a brief tobacco cessation intervention that only a physician or qualified health provider can currently bill, that describe work nurses do every day.

“Comment where you come from, with the experience that you have as a nurse and through your wisdom and through your heart.” – Stephanie Witwer, PhD, RN

Nurses can submit comments on the proposed rule at regulations.gov (docket CMS-2026-2377) until 11:59 p.m. ET on September 14, 2026. Click “Submit a Formal Comment,” and reference file code CMS-1848-P. Deadline: September 14, 2026. 

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🤔 Nurses, weigh in: If nurses had a seat at the table when billing codes were written, what nursing service would you code and pay for first? Share your take in the discussion forum below.

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