Final rule: Conversion factor set for 2.83% reduction in 2025

Jonathan Rubenstein, MD

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule. It outlines CMS updates for payments and policies to take effect on January 1, 2025. A preview is available for download through the Federal Register Public Inspection website: tinyurl.com/4pa9zx6m.

Conversion factor. Without congressional action, the conversion factor (CF) is set to decrease to $32.35 for 2025 from $33.29 in 2024. This is a decrease of 2.83%. The decrease is due to several factors, mainly the expiration of a 1-time increase in the CF of 2.93% from action taken in March 2024 by the US Congress to mitigate the CF reduction that took place at the beginning of 2024. We hope lobbying efforts from organized medicine can mitigate this decrease in the face of inflationary pressures confronting all providers, including urologists. Even if this is successful, urology physician payments likely will fall short of keeping up with inflation.

Mark Painter

Evaluation and Management (E/M) Services revisions, effective January 1, 2025. There are no significant changes for E/M codes for 2025 outside of the Medicare payment for the same services due to CF changes. Although not specifically an E/M code, the Healthcare Common Procedure Coding System (HCPCS) complexity add-on code (G2211) will be expanded to allow reporting this code with additional services such as annual wellness visits, vaccine administration, and preventive medicine visits. No other major changes for G2211 have been proposed. As always, we encourage urology practices to review education materials and protocols and to understand the appropriate use of G2211 for the remainder of 2024 and, based on this document, to prepare to continue using this code in 2025.

The Current Procedural Terminology (CPT) manual introduced a new series of codes for telehealth services, creating codes for audiovisual and audio-only services for new and established patients. The code sets mirror the current Office or Other Outpatient E/M codes by having 4 levels each. Despite these codes being published by CPT and recognized by CMS, these codes (CPT codes 98001 through 98015) have been assigned a status of I by CMS and will not be reimbursed by Medicare (I: Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. This code is not subject to a 90-day grace period.) One code (CPT 98016) was accepted by Medicare for payment and assigned an active status indicator. 98016 describes “Brief communication technology-based service (eg, virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5 to 10 minutes of medical discussion.” This code will replace HCPCScode G2012 on January 1, 2025. With the addition of the 8 new CPT codes for audio-only service (4 levels of new and 4 levels of established patient codes), CPT codes 99441 through 99443 were deleted and will no longer be reportable.

Relative value unit (RVU) changes. Medicare projects that RVU changes for urology will result in a 0.0% decrease in overall RVU production on a similar volume of services for 2025. The Table includes changes for the total RVU by more than 5% (increase or decrease) from 2024. Although the work RVU for procedure did not change, the reduction in total RVU was driven by the practice expense RVU changes. In the proposed rule, Medicare advised changing the reimbursement of certain practice expense supplies for those they felt were potentially misvalued, especially in those packs where the reimbursement for the pack exceeded the cost of the individual supplies. In urology, this affected the supply packs for cystoscopic procedures. Although supply pack for endoscope disinfection (SA042), described as“pack, cleaning and disinfecting, endoscope,” increased from $19.43 to $31.29, the pricing of the “pack, drapes, cystoscopy” (SA045) decreased from $17.33 to $14.99 and the “pack, urology cystoscopy visit” (SA058) was initially reduced from $113.70 to $37.63. Through comments and the efforts of urology associations and individuals, in the final rule Medicare agreed to phase in the changes of supply pack SA058 over 4 years, finalizing a plan to reduce the reimbursement for this pack to $94.68 for 2025, $75.67 for 2026, $56.65 for 2027, and $37.63 starting in 2028.

Telehealth. As noted above, CPT published 17 new telehealth codes. Medicare will not reimburse for 16 of those codes and has advised that practices continue to report the current Office and Other Outpatient E/M services for telehealth services.

Medicare continues to maintain the services listed on the covered telehealth services from categories to permanent or provisional. Of note, CMS has decided to keep code 77427 on the provisional telehealth list for 2025, a change from the proposed rule. Most of the remaining proposed additions or rejected additions were unchanged from that of the proposed rule.( The maintenance of the list indicates that CMS remains highly supportive of telehealth and will continue to develop rules to support payment of telehealth services as allowed by law.

CMS is extending “incident-to” supervision through remote audio-visual “immediate availability” through December 31, 2025, for all services considered clinically appropriate to ease the transition from the public health emergency exemptions and to collect additional data. It has indicated it will permanently allow audiovisual “immediate availability” for certain low-risk services for codes such as 99211 and Professional Component/Technical Component codes with an indicator of 5. CMS proposes to analyze data with concern for patient safety and add codes to this permanent list through future rulemaking.

The current laws covering telehealth services expire at the end of 2024. It will take an act of Congress in an election year to make coverage of telehealth and telephone services permanent for Medicare. The final rule states that telehealth coverage will revert to prepandemic rules on January 1, 2025. We remain hopeful that Congress will kick the can down the road another year. Organized medicine, including the American Urological Association (AUA), continues to lobby for permanently adopting Medicare coverage of telehealth. We encourage all to support your AUA, Large Urology Group Practice Association, American Association of Clinical Urologists, and American Medical Association political action funds and lobby your representatives and senators to support permanent telehealth coverage by Medicare, regardless of political affiliation. We also encourage you to motivate your patients to join the push to make this valuable service permanent.

In this final rule, CMS has also stated that audio-only visits will be considered equivalent to audio-visual visits if the physician/group can offer audio-visual visits to the patient and the patient cannot perform the visual portion due to technical limitations or personal preference. With the deletion of CPT codes 99441 to 99443, CMS has indicated that if a visit is covered and meets the conditions listed above, the audio-only visit would be reported using the E/M code reflective of the service, with modifier -93 appended to indicate audio-only service.

Note: In 2025, Medicare will allow and cover mental health, substance use disorder, and a few limited specially designated services. If Congress allows telehealth to continue under the current rules, the change for reporting telephone-only services will be supported under this final rule, and billing for audio-only visits will be changed to E/M codes under medical decision-making or time with modifier -93.

Modifiers -54, -55, and -56

Modifier -54 is used to append a 90-day global procedure CPT code when the practitioner provides only the surgical care (along with immediate preoperative and postoperative care) but does not provide the remainder of the outpatient postoperative care within the global period. Modifiers -55 and -56 are appended to the same surgical CPT code by a practitioner providing outpatient postoperative global and preoperative care, respectively. These modifiers are used in instances when there is a formal transfer-of-care agreement. Medicare states that it, per data gathered by RAND, conservatively estimates that modifier -54 should be used about 20% of the time for select codes and that these codes are likely underutilized. Medicare aimed to broaden the applicability of transfer-of-care modifier -54 for 90-day global packages to ensure compliance with these rules.

For 2025, Medicare is enforcing modifier -54 for the surgeon who knowingly provides only surgical, preoperative, and immediate (eg, in-hospital) postoperative care. If the operating physician intends the patient to return for follow-up care (eg, no formal agreement), the operating physician may report the service provided without the modifier. If there is a formal agreement, the appropriate practitioners should utilize modifiers -54, -55, and -56. For example, suppose a practitioner knowingly provides follow-up care for a patient. In that case, modifier -55 should be appended to the same CPT code by that provider as the surgeon, who would append their code with modifier -54.

Medicare recognizes that coordinating services or the choice of a patient to not follow the advice of the operating physician are difficult to control and therefore the implementation of a transfer of care based on the care provided is not always in the best interest of the patient. This change will allow Medicare to review the records of the operating physician in cases of separate follow-up care by a different physician of the same specialty to analyze split global payments further. It will be important for physicians providing procedures to indicate instructions for follow-up care clearly; in our review of records, this should not require a significant change in documentation for most urologists.

However, Medicare acknowledges extra work and resources are incurred by a practitioner who did not perform the procedure and is performing postoperative care. Medicare, therefore, finalized a new HCPCS add-on code, G0559, for use when follow-up care is provided by a physician other than the practitioner (or a practitioner within the same group practice) who performed the procedure. This code will be valued at 0.16 work RVU and will be defined as follows:

G0559:Postoperative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90-day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care and requires the following required elements, when possible and applicable:

++ Reading available surgical note to understand the relative success of the procedure, the anatomy that was affected, and potential complications that could have arisen due to the unique circumstances of the patient’s operation.

++ Research the procedure to determine expected postoperative course and potential complications (during a postoperative visit for a procedure outside the specialty).

++ Evaluate and physically examine the patient to determine whether the postoperative course is progressing appropriately.

++ Communicate with the practitioner who performed the procedure if any questions or concerns arise (list separately in addition to office/outpatient evaluation and management visit, new or established).

HCPCS code G0559 would be reported by a physician or other practitioner who did not perform the surgical procedure for a global package and provides related postoperative visits during the global period despite the absence of a formal transfer of care. This code would only be reported with an office or other outpatient E/M during the postoperative global period of 90 days. This code is intended to help offset the additional time, resources, and complexity involved in the first E/M visit following a procedure and may be billed in certain instances when a transfer-of-care modifier was not appended to the claim. Documentation in the medical record should indicate the relevant surgical procedure to the extent the billing practitioner can readily identify it. This code could be billed only once during the 90-day global period for the global package. This code is assigned a ZZZ global period and is reportable with an E/M visit. This code can be reported with a formal transfer of care or when no formal transfer agreement exists. It may be billed by a practitioner of the same specialty as the proceduralist who is not in the same group practice but should not billed by another practitioner in the same group practice as the practitioner who performed the surgical procedure.

Regarding changes to the Merit-based Incentive Payment System, we refer you to our earlier column on the proposed rule: https://tinyurl.com/25ejdbur

Conclusion

The final rule for 2025 poses several challenges to urology. Lobbying efforts to preserve telehealth access and the CF will continue, perhaps dragging into 2025. Practices will have to adjust budgets and once again absorb cost increases while facing cuts to some high-volume procedures. The 0.0% projected RVU impact for urology reflects slight increases in practice expense (PE) values for clinical staff for most procedures to offset the decreases in PE values for the high-volume procedures listed above. The conversion factor, if preserved by Congress, will not offset cost increases for staff and other expenses. As every dollar counts, the battle to preserve the CF to avoid a decrease will need support.

For telehealth, the uncertainty the final rule creates should cause practices to consider how to schedule patients at the beginning of the year. Practices may wish to consider adjusting schedules for traditional Medicare patients regarding telehealth visits. It is recommended that the year be started by informing patients that telehealth will not be available or may be rescheduled due to Medicare rules and encouraging them to call their senator or representative.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.