UCR 017: 2021 CMS Proposed Rules and how they impact the Urology Practices

August 6, 2020

Mark outlines the proposed rule and the 8 items that will have the most impact on the Urology practice.

  1. Final rule posting late this year
  2. Conversion factor decreasing by 10.6%
  3. E&M 2021 changes being adopted and will include increased RVUs for the E&M codes
  4. RVUs for non-facility codes increasing enough to offset conversion factor decrease
  5. RVUs for facility procedures are all decreasing
  6. ASC payments are set to increase
  7. MIPs has a couple of changes but they are not major changes to the current program
  8. Telehealth is going to continue with the same rules during the Public Health Emergency.  Once the PHE is over then covered codes will change and be separated into 3 categories of covered codes

Positive and Negative 2021 RVU adjustment for Non-facility and Facility Urology Codes 50000 - 58000 

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Scott  0:00 

Welcome to the urology coding and reimbursement Podcast, where we help you all just in staff achieve peak economic impact of sufficiency. So there is time and energy, focus on patient care, and a happy life. I'm your host, Scott painter with my co host, Mark painter and Dr. Ray Painter.


Welcome to Episode 17 of the urology coding and reimbursement podcast. Today, Mark is going to take us through what changes are proposed in the rule from CMS and how that's gonna affect the urology practice. So I'm here today with Dr. Ray Painter and Mark painter. And I will turn it over to Mark and Ray and I will ask some clarifying questions as we go through it. But we'll let Mark really go through and break down the new rule or the proposed rule and what's coming up. All right. It's all yours, Mark.


Mark  0:57 

All right. Thanks, Scott. So actually It's kind of interesting, I'm going to start with a couple of high level issues. So first up, the proposed rule is is almost five weeks later than it normally is posted.


So CMS when they when they brought this out, now there's a required comment period of 90 days for that proposed rule. So, essentially to make the proposed rule fit in the timeframe, they stated up front that they are going to invoke a protocol that allows them to post the final rule only 30 days before it goes in to effect on January one, that'll mean that the final rule is actually going to be posted instead of where we normally have two months to prepare to look at all the final decisions. It usually posts on


At the end of November, the beginning of excuse me, end of October beginning of November. Now we're expecting it to come in at the end of November, early December. So we won't be able to make, we won't have as much time to react. Comments are going to have to be, you know, put in place in the while and reacted to while everything's in in place, which is fairly standard. I mean, CMS sometimes makes a few corrections at the last minute, as we've seen the Medicare fee schedule database sometimes posted twice as they clean up some errors, but it's gonna be a quicker time turn around this this time through so we're going to have that to contend with. Another big one is that they are going to in the interest of budget neutrality, they are going to drop the conversion factor by about 10 10.6%


So, the the main reason that they are going to drop that 10.6% is because of the changes in the values and in the projected billing patterns related primarily to e&m codes and codes that are like e&m codes. So we'll get to that in a minute. Now, the good news for urology is that urology as a specialty is protected to be up 8%. Now that as you know what they they look at urology as a specialty, they look at things as a volume based projection. So this is taking all urologists and looking at them the same as going up 8% But as you'll see, as we kind of go through this and you look kind of underneath the covers of what all of the changes are, there are going to be some urologists that actually are paid less by Medicare.


Because of the way they practice in their practice mix is in place and we'll kind of run through that in a minute. Now there was a lot of discussion around the e&m code changes. Remarkably little real estate within the proposed rule was actually dedicated to the e&m changes.


They basically stated that Yep, the decisions they made in 2020 and the 2020 final rule, which were was to adopt the new code structure that is, that is going to be inserted into CPT for established patient visits and new patient visits is going to be adopted and revalued. So you're actually going to see a bump in in the RV use that were assigned to the evaluation and management codes and we're also going to get the benefit of


The changes, of not having to document the history and physical with bullet points and counting things. And everything's going to be driven on medical decision making and time, which is also going to be redefined. And if, you know we're going to be having a number of seminars at the end of September 1 of October, and then probably again, right around the first of the year, to get everybody ready for all these new evaluation and management code changes, which given the way the values are coming in, are going to be extra important this year, to make sure that you really are on top of the e&m code changes.


The e&m code changes and the code change values also affected those codes that are similar or that were based primarily on the e&m code. So some of your your annual well visit code is going to go up because of the change in the RV. Use for


The evaluation management codes, long term care, coordination of care, all of those services that were pretty much e&m like are going to go up. So those of you who are participating in chronic care and are doing some of the, those those services and annual well visits, those are all going to go up as are the e&m codes. So you're going to need to be ready for all of that. And again, we've got some seminars coming up to help you prepare for all of those. Now, the RV use, which is another piece that you do want to take a look at to see why urology is up 8% as opposed to some of the other surgical specialties. Well, one of the reasons is urology does do a lot of office visits from a volume side. Now there are a split specialty urology is a split specialty that has significant amount of procedures


But also a significant amount of just straight face to face, diagnostic and, and, and medical management for therapies. So that's one piece of it. But the other piece of it and one of the things that's very interesting is that the RV use that were assigned that are assigned to the non facility setting. So those things in the office for a lot of our high volume procedures in urology are actually going up enough to offset that 10.6% conversion factor drop. So for services you provide in the office like urodynamics, your, your urolift your rezume, a lot of things that you do through the scope, including small, you know, bladder biopsies, and small bladder tumors.


All of those had an RVU increase that was enough to offset or actually exceed the 10.6% Then conversion factor drop. The same cannot be said for the facility setting. Almost everything in the facility setting is going to see a reimbursement decrease. And, and, in fact, we didn't find a single code that was that the RV use, we're going to jump enough to actually offset the 10.6% drop in the conversion factor. So those of you who do a lot in the hospital or in the ambulatory surgical center, your professional fees are going to go down. Now, I'm going to cross over a little bit. I don't want to spend a lot of time on the on the outpatient or the O PPS rule. But


in general, there has been a bump in the payments that are going to be received by the ambulatory surgical Center and the ambulatory surgical center. Obviously the payments are much greater than what you would get in the office setting. So those of you who own ambulatory surgical centers, the overall impact to you even with a decrease in your non or your facility fees or your professional services will likely be a plus, depending on the mix of services that you provide. So those of you who are not owners in ambulatory surgical centers, and do your services in the hospital, or in the ambulatory surgical center, and don't and aren't sharing in that revenue are going to see decreases on the facility side. So you'll want to take a close look at those RV use. We've got a spreadsheet that will tack at the bottom of this, that will give you a kind of a snapshot of the decrease with the 10.6% projected conversion factor decreaseas compared to the RVU offsets. So so we'll put that at the at the end of this.


MIPS changes are are not going to spend a lot of time in the MIPS changes, a couple of the high level stuff, things that are there is they did shift more of the balance of MIPS onto the cost portion of it. It's jumping from 15% to 20%. And the overall minimum score is going to jump from 45 to 50. So, there are a couple of changes, not big ones, not major structural changes, but changes that you're going to have to be aware of to get up your game. And when we convene our virtual seminar in December, we'll we'll we're bringing back again, Bob Dowling to help us go over the MIPS changes and get you ready for that a little bit closer to the time when that final rule drops. Now, absent from my discussion so far has been telehealth. And that's the other place that


Is that is very interesting and I read a number of different summarizations of the rule change. And of course, we had an executive order from the from the president to make telehealth much more available to seniors permanently. So, the changes that they put in place within Medicare are interesting, not as far as we would like to go but it also gives us a little bit of a window as to what


Sima Verma, the head of HHS is thinking relative to COVID and the public health emergency. So remember that right now, under the public health emergency, a lot of the restrictions on telehealth have been removed. You don't have to have an established relationship with the patient. You can provide telehealth services to the patient at home. You can provide services with phones to the patient and still charge what's equivalent to a level two, three or four, evaluation and management visit. And as long as the public health emergency stays in effect, those are not going to change. What is going to change when the is when the public health emergency expires and the way that the rule is written.


Remember that it's written as a proposed rule for 2021. It really does lead into the assumption that the public health emergency will very likely be extended all the way into 2021. Right now, the public health emergency expires on October 23. The Secretary can only extend the health emergency in 90 day increments. So if they extended it one more time in October, that would mean that the public health emergency would go in January 21, so they only have to extend it one more time.


So, and the way the rule is written, they've added a bunch of codes to the telehealth list and there are three categories of codes in the approved telehealth wrist for Medicare category one codes are codes that Medicare considers the description and the service for an inpatient visit can be closely if not exactly mimicked with a telehealth visit and remember telehealth is audio and visual. So that those are things like office visits and the skilled nursing facility visits, those are the things that were on that 105 approved service lists esrd monitoring, all of those are in that category. Once


Section category two codes are those codes that are not equivalent when you look at the description, but considered to be roughly equivalent in safety and efficacy, if they're provided via telehealth. Those category one and category two codes are added to the telehealth service list. Now, what Medicare is proposing to do is add a third category.


The category three codes, which are considered to be temporary additions to the telehealth service list. And by temporary, what they're saying is that we think that there is an argument to be made, that these codes can be provided safely and safely and, and and efficiently via telehealth. But they don't have enough data to actually make that decision. Permanent. So on the cat 3 code lists. And when they add them to the category three code list, what Medicare is saying is, we're going to continue to pay for these codes through the public health emergency.


And we are going to keep them on the approved telehealth list for the calendar year throughout the end of the calendar year in which the public health emergency ends. So that kind of gives you that lead in because this rule is written for 2021 that they are already thinking that the public health emergency will be extended all the way into January at the very least, given where we are right now. So that's kind of that thought process is that they're making rules that are really based on the public health emergency extending into 2021. And potentially beyond in the way that they're wording all of this so that we'll have to keep an eye on again


The the current expiration of the public health emergency is October 23. With a 90 day extension, that would put it into January. Now, whether or not they're going to push for another 90 days and put it through into the first quarter of 2021, because the the infection rate is still growing or individuals 65 and older are just too afraid to go to the physician office. Those are things that could actually make them extended again, so we'll have to watch that. But these rules are written really to that kind of give us a window into them thinking that the public health emergency is probably going to go past 2020.


So some of the codes that are on the category three red list, which are which are interesting to urology, and there's a number of them on there, and we will include a list that came from the Federal Register of codes that they do decided to add to the category one list, which include home visits. An the new complex GP x code, which is a new code that is going to be an add on to an e&m code. And the the the new pro long service code which is an add on to an e&m code is a telehealth service approved list. So those are going on the permanent list. The category three codes include higher level home visits, emergency department visits, one through three nursing facility discharge visits, rest home visits for and these are all for established patients and the neuro and psych testing.


So those are going to be all added in stuff that's going away. When the public health emergency ends include new patient visits, office visits Excuse me, inpatient visits, high level emergency department visits, new patient visits for the home and observation code visits both new and established. So a lot of the codes that are that were on there are going to be moving away. And I'm sorry, I misspoke. I think the established. Nope, the initial and subsequent observation visits are going away. So those are things that are all going to go away with the public health emergency.


CMS also made the decision that they will not extend the use of telephone only to the past the public health emergency. So right now we're being paid for the 99441 through four three, and some, some g codes for telephone only services specific to ancillary staff. The G 206 series of code adds that are not going to be added to the ongoing paid list. They are still going to allow and try to expand our CTB s list. So you know the G 2010, the G 2012 and the 99420 codes which allow for patient portal exchange and interaction. Those were actually active prior to the public health emergency and those will stay in place. So, they did they did some stuff to actually make telehealth more accessible.


One of the key things they could not do, because law the law prevents it is they cannot allow for new patients or for services provided to patients without an established relationship with the with the physician. So only established patient service services can be provided that that will go away when the public health emergency goes away. And the bigger one is going to be that they cannot allow the place of service to be the patient's home. So they will go back to pre COVID rules, once the public health emergency ends that are that means that the patient has to be in a Medicare approved facility in order for telehealth to be built.


So, it's going to take an act of Congress to actually do that to actually make that in index, in in a permanent allowance to allow patients to get service from home. And so that we're going to encourage you to write your Congress people on to see that they can, they can make the place of service home and then the other one is you can write to CMS, and let them know that at least from our perspective and talking to many of you, the use of telephone only was a key portion for a lot of patients who could not figure out how to use video and audio.


Now CMS is making the definition of telephone different so that a smartphone could work in the way that they're doing it. But it does still require audio and visual to be a telehealth visit, as opposed to the communication technology based services that we have. So that's kind of the the high level summary of everything. A lot of information. Obviously, I'd stumbled around a little bit. I apologize for that. But do you guys have any questions?


Scott  21:46 

So I have a question. Okay. If If your urology practice out there and you're looking at these changes, how would you position your practice to best be perfect Are there any moves that you need to make in the next few months to really take advantage or make sure you're not at risk for anything that that you mentioned?


Mark  22:17 

So number one, I would take a look at whatwhat my capabilities were or my overall revenue impact is for services provided in the office versus the ambulatory surgical center or the hospital outpatient department.


How you're getting reimbursed if it's on work RV use, that shouldn't be an issue. It's the it's the the global payment that's affected. So the work RV use didn't change that much, and in some cases went up a little bit. But take a look at your service mix and if you can bring more into the office if you don't have access to an ambulatory surgical center or facility revenue stream, you want to try and bring more things back into the office. Obviously, if you've got an ambulatory surgical center as part of your practice, you want to weigh which ones, you want to put in the ambulatory surgical center in which you want to keep in the office by looking at the overall not only the only overall revenue, but the overall differential because in the end, what you're trying to do is your take home pay is built on the delta between expense and income. So you want to take a look at that. You absolutely want to prepare for e&m codes and the nm code changes. That's going to be a big impact to the bottom line and a big impact to how you deal with your patients. And ultimately, if you get things set up well, we really think you're going to be able to set up the patient flow better and make better money. So I think those are two big ones. Right now I would I would continue to use telehealth


And see how I can incorporate it into the office. Use this time to pap to practice. But lobby your senators and your Congress, people, there's a couple of bills that are already starting to be to be moved and explored to make the place of service home a viable place for people to get care through telehealth. That that needs to be explored. ramp up your ctbs. And then you might want to take a look at at what you can do with visits to know tele visits to the emergency department and some of those things that are going to continue where the patient is already located in a Medicare approved facility. And then the other thing I would say is that even though these restrictions on telehealth are in place for Medicare, they do not extend to Medicare Part C, nor do they extend to the commercial side. Patients did like the experience telehealth


So, even though we've got some roadblocks here, for doing telehealth for Medicare with new patients and some of the and some of the home visits stuff, I do think that telehealth is going to continue to grow as a demand from the patient side and being able to accommodate that is going to be an efficient use of your practice time. So I'd continue to build your telehealth presence and continue to look at that as an opportunity to extend your reach.


Scott  25:34 



Ray  25:36 

Mark, if I understood you correctly, as an employed physician, since I'm not impacted by anything except my work bad yeah, as far as my bonuses, etc, that if I'm seeing a lot of e&m patients, I should come out on the plus side significantly right?


Mark  26:00 

So yeah, the I mean, the the impact overall of that, that positive 8% you know, includes a 10% reduction on the, on the overall payments. So, if you really look at it from an RVU production side with very few changes, really to the work RV use, and that's really the case.


You're going to come out about the same, not really ahead, about the same for everything but e&m. Now, your e&m as you mentioned, those e&m codes are going up, you know, so, for example, your e&m work RVU for a 213 is going up by about point A almost point two. So, you know, you think about point two times the number of visits you do per year. That is a big bump to your work RV use, and your other ones bump even even higher on those so you're right, even though you're not going to do it.


Much better on your surgeries and some of your in in, in the services that you offer. You are going to do much better with your work RV use on your e&m code. So paying attention to what your e&m codes are is an area that I would focus if I were to work RVU paid individual.


Scott  27:19 

All right, you'd also mentioned a little bit about the e&m workshops that we're going to be hosting and that's one of the other things that I know that you've you recommend strongly is to getting prepared for the e&m changes coming down the pike and we have a new Pocket Card and and wall chart that you're going to need to get familiar with and really learn about the difference is that you're going to need to prepare for so so we do have those and that's on our website. And we'll include the information on the podcast page as well as Mark also mentioned that we have the RV use. And we're going to include the the CPT codes in the 50,000 series and show what the percentage change in total RV use are for the facility and non facility. So we'll include that as well.


Mark  28:20 

Yes, and, you know, of course, we are a little bit biased here, to our own way of doing things. But we do feel like we can provide you with the information that you really need to get to really get on top of and and function well with the new e&m codes. And we do think this is a positive impact for urology, not just on the value side, not just on the documentation side, but from a patient flow side, you can actually to make things move more quickly, not being stuck with as many administrivia details. So we're going to go over all that in the, in the e&m training session. So we're looking forward to doing those. And hopefully we'll see it. We'll have a lot of you join us.


Scott  29:10 

Yes, and we definitely want to make sure you're prepared for 2021. Anything else to add for this? Do we need to cover anything else?


Ray  29:21 

Now Good job, Mark.


Mark  29:23 

Yeah, thanks. Yeah, I mean, obviously, if we uncover other things, as we're going through the it's, you know, it's a short read only about 1400 pages.


So, there may be a few other things and obviously, we would like to have you join us in December to go over the MIPS MACRA changes with Dr. Dowling and let them explore that so because those changes are going to be although not big, they're, they're still important to pay attention to.


Ray  29:56 

And Walmart's referring to is


Scott  30:00 

What mark is referring to is the urology coding and reimbursement seminar. That's going to be online this year, December 4, and fifth. That information we will send out as well.


Ray  30:12 

And Mark since the feds have in their final rule last year, and reiterated this year that they are going to accept the CPT recommended changes for 2021. You're fairly confident that what you're going to be teaching in your e&m virtual seminars are going to be exactly what they're going to be dealing with next year.


Mark  30:44 

I'd say more than fairly confident. I'm at 98%. So it's, it's gonna happen. It's all there. There may be a couple of slight slight tweaks. But the reason we started these webinars at the end of September is that we should already have the CPT publication by then. So we know what CPT is going to do. And we'll know that by the end of September and by our conference. And we know that through the proposed rule and the fact that it was a final rule that CMS is going to do this. There is, the only thing that's out there that might be a bit of a stumbling block, is the fact that a lot of the surgical specialties are going to lose a lot of money as specialties with these changes, and the surgical coalition is lobbying Medicare, to try and mitigate that. Their approach right now, though, is not to delay or hold back, the nm changes, but to ask CMS to waive budget neutrality for this year that you know, with COVID


Everything that's going forward right now, this is not the time to cut the Medicare budget. This is the time to actually make a one time adjustment, add the e&m codes and and not impact the surgical side. So that's what their approaches. Hopefully they'll be successful on that, which would actually be a big winner for everybody but hard to swallow from a money standpoint.


Scott  32:25 

All right. Anything else? Any final thoughts?


Ray  32:28 



Mark  32:29 

That's it for today.


Scott  32:30 

All right. Thank you all for listening, and happy coding. Thank you for listening to the erasure coding and reimbursement Podcast, where we help urologist and staff with cheat sheet economics and practice efficiency, time and energy to focus on. Special thanks to Karl painter for the music today. You can find his music under his record label the juicery with extra poles.