Urology Coding Alert

Focus on these 4 areas that might apply to your practice.

'Tis the season for CMS and others to haggle over the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2018. The proposed rule was issued by CMS a few weeks ago, with updates to payment rates and policies plus quality provisions for services. Read on for some high points of interest to urology practices.

Conversion Factor Could Nudge Higher

The proposed conversion factor for CY2018 is $35.99, which is a small uptick from the 2017 factor of $35.89. This factor includes a -0.03 percent budget neutrality adjustment for relative value unit (RVU) changes and a -0.19 percent adjustment due to the mis-valued code target recapture amount.

Expected effect: According to CMS estimates, the changes reflected in the proposed rule would have an overall impact of -1 percent adjustment on urology services.

Work RVUs for Certain Procedures Could Change

Three urology codes might see adjusted work RVUs (relative value units) in CY18. They are:

• 52601 – Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)  
• 51798 – Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
• 55X87 – Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed.

The reasoning: For code 52601, CMS identified the procedure as potentially mis-valued so is proposing a reduced work RVU for CY18 (from the current 15.26 to proposed 13.16). The CPT^® Editorial Panel created code 55X87 when it deleted Category III code 0438T (Transperineal placement of biodegradable material, peri-prostatic [via needle], single or multiple, includes image guidance) in October 2016. The new, proposed work RVU for 55X87 is 3.03.

E/M and Telehealth Options Expand and Shift

CY2018 will likely bring several new telehealth service codes related to low dose computed tomography eligibility, interactive complexity, health risk assessment, care planning for chronic care management and psychotherapy for crisis. Watch for more information on those and their associated work RVUs, and whether they might apply to your practice. In the future, the use of telehealth service codes will increase for urology and other specialties, predicts Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York, University Hospital and Medical School, Stony Brook, NY.

E/M codes could also see changes. CMS is currently seeking public comments related to E/M service code updates, especially for the history of present illness and physical examination components for E/M office visits. They may be eliminated or documentation requirements significantly changed, Ferragamo warns.

Quality Initiative Measures Could See Changes

The current PQRS program policy requires physicians to report on nine clinical quality measures across three National Quality Strategy domains – or see a negative 2.0 payment adjustment in the physician fee schedule (PPS) in 2018. In the proposed rule for CY18, however, CMS proposes reducing the PQRS reporting requirement to only six measures to align with the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program.

There's more: CMS proposed similar changes to the clinical reporting requirements under the Medicare Electronic Health Record (EHR) Incentive Program. CMS also proposes to reduce the automatic value modifier (VM) payment adjustment from -4.0 percent to -2.0 percent for clinician groups of 10 or more, and from -2.0 percent to -1.0 percent for solo and groups with less than 10 clinicians.