How the 2025 Medicare proposed rule may affect urology

Jonathan Rubenstein, MD

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule. It outlines CMS’ proposed updates for payments and policies starting January 1, 2025. As always, there is a comment period after which CMS must respond and react to the comments received, which will be published in the Final Rule that is typically released in November. Comments can be posted online by going to the following website and submitting a formal comment. Please refer to file code CMS-1807-P and go to https://www.regulations.gov and follow the “Submit a comment” instructions. Below are some of the most notable proposed rules that may interest urologists and urology practices.

Mark Painter

Conversion factor (CF): The CF for 2025 is proposed to decrease to $32.36 from $33.29 in 2024. This is a decrease of 2.80%. This decrease is due to several factors, but mainly the expiration of a 1-time 2.93% CF increase from action taken by the US Congress to mitigate the 2024 CF drop in March 2024, and a slight increase of 0.05% to account for work relative value units (RVU) changes. This continues the troubling trend of year-after-year physician payment reductions for the same work being performed.

Evaluation and Management (E/M) Services proposed revisions, effective January 1, 2025:

No significant changes are proposed for E/M codes for 2025. Although not specifically an E/M code, the Healthcare Common Procedure Coding System complexity add-on code, G2211, will be expanded to allow for reporting this code in conjunction with annual wellness visit codes, vaccine administration, and preventive medicine visit codes. 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 to use this code in 2025.

Delayed implementation of the updated Medicare Economic Index (MEI) weights: Again, CMS proposes to delay the implementation of the weights based on MEI relative to the Medicare Fee Schedule. These numbers were finalized in the 2023 Final Rule; however, CMS proposes to delay this implementation and others to collect and further analyze data related to physician practice expenses.

RVU changes: Medicare projects that RVU changes for urology will result in a 1.0% decrease in overall RVU production on a similar volume of services for 2025. The Table accompanying the full version of this article online (tiny url) includes RVU changes that affect the total value up or down more than 5% from 2024. The only code that increased in value is Post-Void Residual (PVR), which increased slightly over 5%. In addition, several codes will see their Practice Expense (PE) valuation change due to updates in supply valuation by the CPT Relative Value Unit Update Committee (RUC).Most notably for urology, the:“pack, cleaning and disinfecting, endoscope” (SA042) supply changed from $19.43 to $31.29; the pricing of the “pack, drapes, cystoscopy” (SA045) supply changed from $17.33 to $14.99; and the “pack, urology cystoscopy visit” (SA058) supply changed from $113.70 to $37.63, resulting in a net decrease for the reimbursement for urology practice expense for codes that include the use of cystoscopy.

Telehealth: In the proposed rule, Medicare recommends changing the categorization of services listed on the covered telehealth services from categories to permanent or provisional. This further indicates that CMS remains highly supportive of telehealth and will continue to develop rules to support payment of telehealth services as allowed by law. Several Current Procedural Terminology (CPT) codes were submitted to Medicare for consideration for addition to the approved telehealth service list, including 64566 and 74427 (both rejected by CMS). CMS agreed that a few of the CPT code requests for addition to the list met the criteria to be added as provisional, including a few physical therapy codes for patient evaluation and training, such as 97750. Two codes, G0011 and G0013, were added to the list as permanent, and both codes focus on preexposure prophylaxis for HIV counseling.

CMS proposes extending “incident to” supervision through remote audio/visual “immediate availability” through December 31, 2025, for all services to ease the transition from the Public Health Emergency exemptions and to collect additional data. They are also proposing permanent allowance of audio/visual “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 proposed rule reflects this, stating that telehealth coverage will revert to pre-pandemic rules on January 1, 2025. Without a permanent rule, 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, LUGPA, American Association of Clinical Urologists (AACU), and American Medical Association (AMA) political action funds, as well as 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.

The AMA has developed new codes for telehealth, which will be addressed in our October column after they are officially released in September. CMS has proposed values for these codes that are slightly lower than the existing office visit codes but above current values for non-facility valuation. In the proposed rule, these codes are listed as status “I,” which indicates they are not valid for Medicare purposes. The values appear to represent a compromise between current policy and the reality of the current COVID-19 rules that extend telehealth parity to in-person visits. The codes’ status reflects current law and the scheduled expiration of telehealth coverage noted above.

Modifiers -54, -55, and -56

Medicare is again reviewing the global package and payments surrounding postoperative services provided by a physician other than the surgeon. Medicare has conducted multiple experiments over the years, including voluntary reporting of post-operative visits and internal data analysis. For 2025, Medicare is considering removing the formal transfer of care requirement for the use of modifiers -54, -55, and -56. If the proposal is adopted, this may require the physician who knows the patient is not going to return for follow-up care to report the procedure code with modifier -54 and the physician providing the postoperative care with the same procedure(s) with modifier -55 appended instead of reporting E/M follow-up codes, regardless of whether a formal transfer of care is included in the patient record. Medicare acknowledges that communication and billing are problems. However, we did not see an acknowledgment for those physicians providing the service and intending to provide follow-up care without a patient return when a physician of the same specialty provides the follow-up care.

However, Medicare acknowledges the extra work required by a physician providing follow-up care if the physician is not of the same specialty. Medicare is proposing a new add-on code for use when follow-up care is provided by a physician of a different specialty than the physician who performed the procedure as follows:

GPOC1:Post-operative 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 a different specialty than the practitioner who performed the procedure, within the 090-day global period of the procedure(s), once per 090-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 post-operative course and potential complications (in the case of doing a post-op for a procedure outside the specialty).

● Evaluate and physically examine the patient to determine whether the post-operative 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)

This proposal is based on existing rule sentiment. We will watch this closely based on comments and the final rule.

Merit-based Incentive Payment System (MIPS):

The Quality Payment Program continues to evolve yearly. The goals of the updates are to focus more on alignment while providing new options for clinicians to participate in a more meaningful way and to achieve continuous improvement in the quality of health care services provided to Medicare beneficiaries and other patients through the Quality Payment Program’s MIPS and Advanced Alternative Payment Models for the CY 2025 performance period/2027 MIPS payment year.

For those participating in MIPS, the scoring weights for 2025 will be as follows:

30% quality performance category

30% for the cost performance category

15% for the improvement activities performance category

25% for the promoting interoperability performance category.

CMS continues developing new MIPS Value Pathways (MVPs) for more participation. MVPs connect activities and measures from the 4 MIPS performance categories (quality, cost, improvement activities, promoting interoperability) relevant to a specialty, medical condition, or a particular population. One of the proposed MVPs relevant to urology this year is “Optimal Care for Patients With Urologic Conditions MVP.” This urology specialty MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions, including kidney stones, urinary incontinence, bladder cancer, and prostate cancer. The MVP is created to be used by general urologists, urology oncologists, and subspecialists focused on urology care for women, including nonphysician practitioners such as nurse practitioners and physician assistants. For the quality category, the proposed MVP includes 9 MIPS quality measures and 5 QCDR (Qualified Clinical Data Registry – data reporting through a qualified data registry vendor) measures most relevant to urology; there are 17 improvement activities proposed for inclusion, 16 promoting interoperability measures, and the proposed cost measures include Medicare spending per beneficiary, renal or ureteral stone surgical treatment, and prostate cancer measures. The details of this MVP will be addressed in a future publication.

Conclusion: We will update you again once the final rule is released, typically in late October or early November. We encourage you to comment on this proposed rule as you feel appropriate and to coordinate, where possible, with LUGPA, the AUA, and the AACU.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. 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.