Urology Coding Alert

Final Rule:

Outline Crucial 2021 MPFS Final Rule Changes for Urology

Published on Wed Jan 13, 2021

Look beyond E/M to get the most out of the final rule.

The 2021 Medicare Physician Fee Schedule (MPFS) final rule includes a series of notable changes and policy revisions that will have a profound impact on your urology practice. However, to understand the scope of these changes, it’s important that you look beyond the evaluation and management (E/M) highlights to consider what else within the final rule may have influence your day-to-day coding.

“The overwhelming focus for the MPFS final rule changes has been on 2021 E/M,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CRC, CEDC, CGIC, HIM Coding Specialist at Dignity Health Yavapai Regional Medical Center in Prescott, AZ. “However, there are many other important changes coming in 2021 that require careful review and preparation for any coding professional,” Kemp explains.

Specifically, there are two areas of emphasis within the final rule that urology coders, billers, and physicians should home in on. First, you should take note of the revised rules on diagnostic testing and medical record review designed to give non-physician practitioners (NPPs) an expanded level of access and control. Next, among a host of changes to Merit-based Incentive Payment System (MIPS) measures, there’s one urological measure to which you should pay special attention to.

Round out your 2021 MPFS final rule knowledge with these two important areas of consideration.

Consider Loosened NPP Supervision Restrictions

Under the MPFS regulation at §410.32(b)(1), the Centers for Medicare & Medicaid Services (CMS) has amended the guidelines on diagnostic supervision to allow certain NPPs to perform diagnostic supervision services without a “general level of physician supervision.” In other words, NPPs are now eligible to perform and bill for specific qualifying urological diagnostic services without a physician present. Previously NPPs were allowed to order diagnostic tests, but only the patient’s physician could supervise the diagnostic testing.

“In place of supervision exclusively by the physician, a qualified NPP (typically a physician assistant) can now supervise diagnostic tests that are performed by a nurse or medical technician,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. Some of these tests may include 74420 (Urography, retrograde, with or without KUB), 74485 (Dilation of ureter(s) or urethra, radiological supervision and interpretation), and 76870 (Ultrasound, scrotum and contents).

“Keep in mind that the NPP won’t be supervising physicians, but rather qualified staff such as registered nurses or medical technicians who are trained to perform such services, but cannot do so without required supervision,” Ferragamo explains.

The justification for such a change is based on the fact that NPPs are already eligible to perform such services under many states’ scope of practice rules. These rules were initially implemented in May 2020 as a means of easing the burden on providers during the public health emergency (PHE). Following suit with a variety of other previously “temporary” guidelines, CMS has decided to permanently implement this new diagnostic supervision policy. According to CMS, NPPs “are authorized to receive payment under Medicare Part B for the professional services they furnish either directly or ‘incident to’ their own professional services.”

With respect to urology, CMS considers the following sets of NPPs eligible for diagnostic supervision services:

Nurse practitioners (NPs)
Clinical nurse specialists (CNSs)
Physician assistants (PAs)
Certified registered nurse anesthetists (CRNAs)

Refresher: In the 2020 MPFS final rule, CMS added further autonomy to the role of NPP by stating that both physicians and NPPs can “review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the MPFS.”

To consider: According to NP and PA CMS guidelines, Medicare pays services “at 80% of the actual charge or 85% of the amount Medicare pays a physician under the Medicare Physician Fee Schedule (MPFS).”

Avoid MIPS Measure #476 Reporting for Telehealth Visits

In order to stay on top of your MIPS reporting, you should consider a few substantiative changes made to existing measures you’ll consider for applicable clinical encounters. First, take a look at quality measure #476, which you report for a “Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.”

First and foremost, you will notice that the title of this measure has been mercifully shortened to the following: “Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia.” However, the most fundamental change has to do with the reporting of measure #476 for telehealth services. During the PHE, CMS has had to clarify which quality measures should and should not be reported for telehealth visits.

In the CMS document “Telehealth Guidance for Electronic Clinical Quality Measures (eCQMs) for Eligible Professional/ Eligible Clinician 2021 Quality Reporting,” you will find an updated list of measures that CMS deems eligible and ineligible for reporting as a telehealth visit. You will find quality measure #476 falls within Table 2: Not Eligible for Telehealth Encounter Electronic Clinical Quality Measures for Eligible Professionals and Eligible Clinicians: 2021 Reporting.

More specifically, CMS states the following for any measures listed in Table 2: “Telehealth is not appropriate for encounters within these eCQMs for performance period 2021. Medicare telehealth-eligible codes found in any encounter value set in these measures cannot be used for telehealth encounters and must only be used for in-person encounters for these eCQMs.” For 2021 and beyond, you should not report measure #476 for clinically eligible patients when the physician or NPP renders a telehealth service.

You can access the complete list of Table 1 and Table 2 MIPS measures at https://ecqi.healthit.gov/sites/default/files/2021-eCQM-Telehealth-Guidance-Document-With-QRDA-Update-508.pdf.