Urology Coding Alert

As you work your way through the Medicare Physician Fee Schedule (MPFS) 2021 proposed rule, you’ll notice an underlying theme with respect to physician reimbursement: There’s less of it. Especially when it comes to surgical specialties, Medicare’s proposal to cut the conversion factor could have a profound impact on many practices’ bottom lines.

However, while this proposed rule results in less overall reimbursement for most practices, you’ll be pleased to know that urology is one of the few specialties to see a substantial bump in Medicare reimbursements.

Keep reading for a glimpse into what kind of impact this proposed rule will have on the reimbursement landscape in 2021.

Check Out Shift in Conversion Factor

The bottom lines for most physician practices will take a hit, thanks to CMS aiming to cut the conversion factor (CF) by 10.61 percent. According to the proposed rule, Section 101(a) of MACRA changed the way the CF is calculated; plus, the office/outpatient E/M payment rate changes influenced the agency’s decision to lower the CF.

“With the budget neutrality adjustment to account for changes in [relative value units] RVUs, as required by law, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09,” CMS indicates.

Remember: The national CF is what you use when calculating payment when your providers perform surgical services such as nephrectomies, radical prostatectomies, and cystectomies etc., reminds Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Do the math: The CF is the multiplier with the relative value units (RVUs) assigned to each procedure code, adjusted for geographic region, and calculated as the payment amount.

CMS offers a breakdown of the expected impacts from the payment rate change by specialty in the proposed rule. The details are in Table 90; however, annual changes, volume of patients, and types of services offered will also greatly affect Medicare revenues, says Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in a blog post.

See How Urology Fares Among Other Specialties

Under the proposed rule, you can expect Medicare payments to decrease by 7 percent for general surgery, 7 percent for vascular surgery, 8 percent for thoracic surgery, and 9 percent for cardiac surgery compared to 2020 rates. However, urology practices will be pleased to know that their specialty is one of the few resulting in a positive net impact. In other words, urology providers should expect a net 8 percent boost in revenue based on a $1.803B increase in allowed charges.

That’s in part due to the urology specialty’s high output of evaluation and management (E/M) visits as compared to other, more surgically oriented specialties. Generally speaking, those specialties that focus more exclusively on surgeries, rather than E/M visits, will see their revenue share decrease in 2021.

Public outcry: As expected, industry organizations are rattled by the major CF dip, especially in the midst of COVID-19 spikes. Backing up cash-strapped providers, the American Medical Association (AMA) urged Congress to get involved before the final rule is released later this year.

“The AMA appreciates that CMS will implement significant increases to the payment for office visits, based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC),” acknowledged AMA President Susan R. Bailey, MD, in a statement. “Unfortunately, these office visit payment increases, and a multitude of other new CMS proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11 percent to the Medicare conversion factor.”

Bailey added, “For this reason, the AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases. Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time.”

Surgeon stakeholders: “We support steps to expand access to care, but this rule takes one step forward and several steps back by disregarding patients’ needs and the surgeons who care for them,” said David B. Hoyt, MD, FACS, American College of Surgeons Executive Director in a statement with the Surgical Care Coalition. “The middle of a pandemic is no time for cuts to any form of health care, yet this proposed rule moves ahead as if nothing has changed. The health care system cannot absorb cuts of this magnitude.”

Supervision Updates Are Extended

CMS adopted an interim final policy for the duration of the public health emergency (PHE) related to the COVID-19 pandemic that revised the definition of “direct supervision;” the new definition included virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications (85 FR 19245). The update was made because CMS realized that, in some cases, the physical proximity of the provider might increase infection exposure risk to the patient and/or provider.

Update: The CY 2021 MPFS proposed rule allows direct supervision to be provided using real-time, interactive audio/video technology through Dec. 31, 2021 (excluding telephone calls that do not also include video).

The proposed rule also includes interim policy changes for supervision services of teaching physicians: Teaching physicians may use audio/video real-time communications technology to interact with a resident through virtual means, to meet the requirement of being present for the key portion of the service.

However: This virtual supervision allowance might not apply to all surgery cases. An excerpt of the proposed rule reads: “While flexibility to provide direct supervision through audio/video real-time communications technology was adopted to be responsive to critical needs during the PHE … [this]… may not be sufficient to support PFS payment on a permanent basis, beyond the PHE, due to issues of patient safety. In complex, high-risk, surgical, interventional, or endoscopic procedures, or anesthesia procedures, a patient’s clinical status can quickly change. To permit payment under the PFS for these teaching physician services, we believe the services must be furnished with a certain level of personal oversight and involvement of the teaching physician who has the experience and judgment that is necessary for rapid on-site decision-making during these procedures.”

The proposed rule was published in the Federal Register on August 17 and is available at www.govinfo.gov/content/pkg/FR-2020-08-17/pdf/2020-17127.pdf. CMS expects to publish the final rule no later than Dec. 2, 2020, which is a 30-day delay from the normal publication date due to the COVID-19 PHE.