urology practices: The Centers for Medicare & Medicaid Services (CMS) unveiled its proposed Medicare Physician Fee Schedule for 2025 on July 10, 2024. This outlines potential payment adjustments and policy changes that would take effect starting January 1, 2025. A public comment period will follow, during which CMS will gather feedback to inform the final rule, typically released in November.
Key Proposed Changes for Urologists in the 2025 Medicare Physician Fee Schedule
The CMS proposed Medicare Physician Fee Schedule for 2025 includes several significant changes that will impact urologists:
- Conversion Factor (CF) Reduction: A 2.8% decrease in the CF is proposed for 2025, primarily due to the expiration of a temporary increase enacted in 2024. This continues a pattern of declining reimbursement for physician services.
- No Major E/M Code Changes: While there are no substantial changes to Evaluation and Management (E/M) codes, the complexity add-on code G2211 will be expanded to include use with wellness visits and vaccine administration.
- Delayed MEI Implementation: CMS is again proposing to postpone the implementation of updated Medicare Economic Index (MEI) weights, citing the need for further data analysis on physician urology practices expenses
- RVU and Payment Changes
The proposed 2025 Medicare Physician Fee Schedule indicates a projected 1% decrease in overall RVU value for urology services. A detailed analysis of RVU changes can be found in the accompanying table (link). Notably, Post-Void Residual (PVR) codes saw a slight increase, while several supply codes used in urology, such as those for cystoscopy packs, experienced significant reductions. These changes will likely impact urology practices reimbursement.
- Telehealth Updates
CMS proposes shifting telehealth service categorization from temporary to permanent or provisional status, signaling continued support for telehealth. While some new CPT codes for telehealth were not approved, others, including physical therapy evaluation and HIV counseling codes, were added.
The agency also plans to extend “incident to” supervision for telehealth services through 2025 and is exploring permanent options for certain low-risk services. However, the future of telehealth beyond 2024 remains uncertain, as current laws expire at the end of the year.
The AMA has introduced new telehealth codes, which will be evaluated in detail in a future article. CMS has assigned preliminary values to these codes, but their status as non-valid for Medicare purposes reflects the current legal landscape.
Advocacy efforts are crucial to secure permanent telehealth coverage. Urologists are encouraged to support professional organizations and engage with lawmakers to ensure continued access to this valuable service.
Modifiers -54, -55, and -56: Medicare Proposes Changes to Postoperative Billing
Medicare is reconsidering its policies on postoperative services provided by physicians other than the surgeon. After conducting various studies, Medicare is proposing to eliminate the formal transfer of care requirement for using modifiers -54, -55, and -56 in 2025.
If this change is implemented, physicians who know a patient won’t return for follow-up care could use modifier -54 for the procedure, while the physician providing postoperative care would use the same procedure code with modifier -55, regardless of whether a formal transfer of care exists. This would replace the current urology practices of using E/M follow-up codes.
Medicare acknowledges the potential challenges in communication and billing but has not addressed concerns about physicians providing follow-up care without a patient return when both physicians are in the same specialty. However, Medicare recognizes the increased workload for physicians in different specialties providing follow-up care.
To address this, Medicare is introducing a new add-on code, GPOC1. This code is for postoperative follow-up visits by a physician of a different specialty than the surgeon, within the 90-day global period. It covers additional work such as reviewing surgical notes, researching the procedure, evaluating the patient, and communicating with the surgeon.
Medicare will monitor feedback on this proposal and make adjustments as needed based on comments and the final rule.
Merit-based Incentive Payment System (MIPS): An Overview
The Merit-based Incentive Payment System (MIPS) is a Medicare program designed to encourage high-quality, efficient care. It replaces several previous programs and offers clinicians financial incentives for meeting performance goals. MIPS are part of the larger Quality Payment Program (QPP), which is continually evolving to provide more flexibility and opportunities for improvement.
MIPS for 2025
For the 2025 performance year, MIPS will be scored across four categories:
- Quality (30%): Measures how well clinicians provide care.
- Cost (30%): Evaluates the efficiency and cost-effectiveness of care.
- Improvement Activities (15%): Recognizes efforts to enhance care processes.
- Promoting Interoperability (25%): Rewards the use of technology to improve care coordination.
MIPS Value Pathways (MVPs)
To simplify participation, CMS is developing MIPS Value Pathways (MVPs) focused on specific specialties or conditions. One proposed MVP is for urology, targeting optimal care for patients with urologic conditions such as kidney stones, urinary incontinence, bladder cancer, and prostate cancer. This MVP includes measures from all four MIPS categories and is designed for urologists, urology oncologists, and urology-focused non-physician practitioners.
Key Components of the Urology MVP
- Quality: 9 MIPS quality measures and 5 QCDR measures.
- Improvement Activities: 17 proposed activities.
- Promoting Interoperability: 16 proposed measures.
- Cost: Medicare spending per beneficiary, renal or ureteral stone surgical treatment, and prostate cancer measures.
Allzone Management Services: Enhancing Charge Capture Accuracy
Allzone Management Services is a healthcare revenue cycle management company that specializes in improving charge capture accuracy. This is a critical aspect of healthcare billing as it directly impacts the revenue generated by a healthcare provider.
How Allzone Improves Charge Capture Accuracy
Allzone employs a combination of human expertise and technology to enhance charge capture accuracy. Here’s a breakdown of their approach:
- Dedicated Charge Entry Specialists: Their team consists of experienced professionals who understand the intricacies of medical coding and billing. They ensure that all charges are entered correctly and completely.
- Advanced Software: Allzone utilizes state-of-the-art medical billing and coding software to streamline the charge capture process. This technology helps to minimize errors and improve efficiency.
- Quality Control Measures: Rigorous quality control checks are in place to identify and correct any discrepancies in the charge capture process.
- Charge Capture Audits: Allzone conducts regular audits to assess the accuracy of charge capture and identify areas for improvement.