Urology Coding Alert

Plus: Learn two new HCPCS Codes if your urologist performs wellness visits.

Get ready for another year of nail-biting to find out whether your Medicare payments will be slashed. "The calendar year 2011 Physician Fee Schedule conversion factor is $25.5217," notes the 2011 Medicare Physician Fee Schedule Final Rule, printed in the Federal Register that will be published on Nov. 29. This amounts to a dismal 30.7 percent cut compared to the current rate of $36.8729.

"While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical," the Fee Schedule notes. "We are committed to permanently reforming the Medicare payment formula."

Good news: As you know, last June, Congress voted to not only stave off a 21 percent cut to your Medicare pay, but to increase your revenue by 2.2 percent. That vote kept the cuts at bay through November 30. However, effective December 1,your Medicare pay was to drop by over 23 percent. To prevent this from happening the Senate acted rapidly and, on November 19, voted to postpone this cut and to maintain the conversion factor at $36.8729 until December 31, 2010. Later this month the House is expected to also approve the continuation of the present conversion factor for the remainder of 2010, and then the president is expected to sign this Congressional bill.

Because of the flawed Sustainable Growth Rate (SGR) formula to calculate Medicare fees, however, Medicare payments to physicians are also due to fall starting January 1, 2010, and medical practices will face a perfect storm of payment nightmares.

Practices continue to be in the dark about what will transpire on Jan. 1. "We have no idea what will happen in Congress in January regarding the conversion factor," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "Some newly elected Senators and House members will be in place in 2011, and it is unclear whether the current Congress will make changes affecting 2011 pay before January, or whether they'll leave these issues for the new Congress to solve," he says.

Urology Will Suffer Even Further

In addition to dealing with conversion factor fluctuations, some specialties will face additional cuts. While the hardest hit practices will be those that specialize in radiology, the cuts will most definitely have a significant impact on specialty practices that are already financially stretched.

Urology, unfortunately, ranks among the specialties that will face the biggest Medicare cuts in 2011 based on changes to relative value units (RVUs) assigned to codes and other adjustments in certain specialties. Keep in mind that these numbers do not include the impact of the January 2011 conversion factor changes. However, without the conversion factor cut RVU changes will still cause urology practices to see at least a 3-4 percent decline in Medicare reimbursements next year.

CPT Establishes Annual Wellness Visit Codes

The Fee Schedule also incorporates several provisions of the Affordable Care Act of 2010 that was passed in March. First and foremost, you'll see that coverage has been established for annual wellness visits for Medicare patients. "The rule we are issuing today is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to develop a closer partnership to improve the patient's long term health," said CMS administrator Donald Berwick, MD in a Nov. 3 statement.

If you perform a procedure that meets CMS's description of an annual wellness visit, you should not report a code from CPT's preventive medicine section to your Medicare carrier, the Final Rule indicates. CMS does not pay for preventive medicine services billed under 99381-99397. Instead, report one of the following newly established HCPCS codes:

G0438 -- Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 -- ... subsequent visit.

"Although most of these wellness examinations are usually performed by the patient's internist or family physician, occasionally a urologist will perform this service," Ferragamo says. "If so, consider the above codes and information to help you properly bill and be paid for this wellness examination service."

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 RVUs to G0439, and these codes will be effective on Jan. 1, 2011. Beneficiaries who have only been enrolled in Part B for 12 months will be eligible for an initial preventive

physical exam, (also known as an IPPE, which is billed with G0402). "After the first 12 months of Part B coverage on or after Jan. 1, 2011, beneficiaries would be eligible for an annual wellness visit" as described by the new G codes, assuming that patient has not had an IPPE within the preceding 12 month period, the Fee Schedule states. To read the 2,023-page Final Rule in the Federal Register, visit www.ofr.gov/OFRUpload/OFRData/2010-27969_PI.pdf.