Comment on CMS-2026-2377-0002

Re: CMS-1848-P — CY 2027 Medicare Physician Fee Schedule Proposed Rule I am a DNP, APRN, BSN, RN with 24 years of experience currently working in a health tech setting. I am submitting this comment on the proposed rule above. Over two decades of care across multiple settings is difficult to distill. I've worked in med-surg, critical care, pulmonary, primary care and digital health. I've served in infection control, safe patient handling, quality improvement, bringing new technology to the bedside, engaging in innovation. I've contributed to the literature. When I worked inpatient, my work was hidden in the room and board. When I worked ambulatory, my work was simply called 'non-billable' and largely dismissed. When I co-developed a solution for patients and care teams to help avoid missed care, the financial incentives were misaligned to the point that a health system that prides itself on innovation would not invest to develop it BECAUSE there was no path to reimbursement, although the ONLY way care is reimbursed is often through the work of nurses. If we truly want America to be Healthy Again, we could do no better than to begin where the care of nurses starts and incentivize that care by making it reimbursable and billable. Here is some of what my direct care has meant, in terms Medicare already measures. Under ambulatory quality measures: patients kept stable at home instead of the ER (20-40 plus hours per week x 4 years. average of 15-30 calls per day. Unknown number of triage mychart messages. Arranging pulmonary function tests to match with clinic visits to avoid repeat transportation visits. Decreasing no show rates by outreaching ahead and rescheduling.); more patients than I could ever count brought in for screening, immunization, or follow-up because a nurse chased it (As an NP in a high risk primary care clinic, I worked with my MA and my RN's to have all care gaps, screenings, vaccine orders pended ahead of the appointment. I would then spend part of the appointment providing encouragement and seeking agreement to order the screenings. This allowed my patients to get their screenings done on their own time in the next 365 days. My nurses would then follow up). Under CMS health-equity and SDOH screening measures: more patients than I could ever count connected to care that would otherwise have been missed entirely, because a nurse noticed (One day I met with a patient who had 'resistant hypertension' on her chart. Sure enough, extremely high blood pressure despite 4 antihypertensive medications. We had been over and over her medication list, avoiding salt etc. I finally asked her to bring in all medication bottles. I lined them up. We went one by one. We confirmed they matched. I then asked her to tell me exactly how she took the BP meds. She said "I close my eyes, I pray and I put my hand out and pick one. I take that one." That day profoundly changed how I think about nursing care. We started over, began with one medication, with salt control, regular check ins and adherence to the prescription. Her BP was ultimately controlled on two medications). Under nurse-led quality and safety improvement: nurse designed safety process (My nurse co-founder and I built an entire patent pending tool to keep patients on their care plans after noticing patients kept 'disappearing' from expected care. When we asked our health system to develop it with us, they said no, because the work of nurses is non billable. 11 years later, we are still looking for a health system that will engage in this work but now, the reasons given for not partnering have expanded from the work is non billable to deciding to wait until the EHR builds the same tool). Much of nursing is harm prevented before it happened: nursing assessment, judgment and intuition applied reliably, to every patient. Medicare measures and pays for these outcomes, yet the nursing work behind them is bundled into room-and-board or other clinicians' billing — invisible in claims data, ineligible for reimbursement, and absent from the quality metrics these programs use. CMS: fix this misalignment and build codes that let nursing work be seen, counted, and reimbursed. I support CMS's interest in alternatives to the current process for valuing CPT codes--starting with NIC and NOC, TCM, CCM and RPM codes would be reasonable. I urge CMS to establish an independent, multidisciplinary body — including nurses and nurse practitioners — to take part in valuing codes, especially those tied to AI-supported care, so that everyone who delivers that care is represented in how it is valued. From my own practice: help nurse-built tech find a seat at the table. We are solving our own problems but cannot get a foothold, often due to culture, the history of nurses work being non billable and the limits imposed by EHRs on innovation. Thank you for considering these comments. Sincerely, Kelly Ayala, DNP, APRN, BSN, RN