On November 2, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and rates for services furnished under the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2017. In the rule, CMS finalizes several proposals that will improve payment for urologic services. In addition, CMS will implement new codes for telehealth consultation services and modify the electronic health record (EHR) quality measure for accountable care organizations (ACOs) under the Medicare Shared Savings Program to align with the new Quality Payment Program.
0-day Global Services that are Typically Billed with an Evaluation and Management (E/M) Service with Modifier 25: The AUA successfully advocated for removal of CPT codes 51701 (Insertion of temporary bladder catheter), 51702 (Insertion of indwelling bladder catheter) and 51703 (Insertion of indwelling bladder catheter) from the list of potentially misvalued services. In the proposed rule, CMS identified 0-day global codes billed with an Evaluation and Management (E/M) service 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary, that have not been reviewed in the last five years, and with greater than 20,000 allowed services. CMS acknowledged that these services were in fact reviewed in the last five years, and therefore do not meet the criteria of the review screen.
Collecting Data on Resources Used in Furnishing Global Services: In response to concerns raised by the AUA and the collective medical community, CMS adopted a modified data collection process for 10 and 90-day global services. Instead of requiring use of a series of G-codes for this purpose, CMS finalized the following claims-based data collection process:
- CPT code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an E/M service was performed during a postoperative period for a reason(s) related to the original procedure) will be used for reporting post-operative services rather than the proposed set of G-codes. Reporting will not be required for pre-operative visits included in the global package or for services not related to patient visit.
- Reporting will be required only for services related to codes reported annually by more than 100 practitioners and that are reported more than 10,000 times or have allowed charges in excess of $10 million annually.
- Practitioners are encouraged to begin reporting post-operative visits for procedures furnished on or after January 1, 2017, but the mandatory requirement to report will be effective for services related to global procedures furnished on or after July 1, 2017. Only practitioners who practice in groups with 10 or more practitioners in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island will be required to report. Practitioners who only practice in smaller practices or in other geographic areas are encouraged to report data, if feasible.
CMS will not require time units or modifiers to distinguish levels of visits to be reported at this time, except for teaching physicians who will be required to use the GC or GE modifier as appropriate. To supplement claims-based reporting, CMS will conduct a survey of practitioners to gain information on post-operative activities. CMS confirmed that the statutory provision that authorizes a five percent withhold of payment for global services until claims are filed for the post-operative care will not be implemented.
Laparoscopic Radical Prostatectomy (CPT code 55866): For CY 2017, CMS will implement the 26.80 work RVU recommended by the AMA Relative Value Scale Update Committee (RUC). In the 2016 Medicare Physician Fee Schedule final rule, CMS reduced the work RVU for CPT 55866 from 32.06 to 21.36 on an interim basis, representing a 33 percent cut to be phased in over a two year period. In March, representatives of the AUA and LUGPA met with a multi-specialty Refinement Panel to discuss CMS’ decision, the difference in a prostatectomy using a robotic versus an open technique, and presented new data to support the RUC-recommended work RVU. CMS notes in the rule that the results of the study “presents additional data indicating that there is a significant difference between the open and robotic-assisted forms of laparoscopic radical prostatectomy, and that the robotic form described by CPT code 55866 likely takes a longer time to perform” as such, “the recommended work RVU of 26.80 is a more appropriate value for this procedure.” A full report on the AUA’s advocacy efforts with the Refinement Panel is available online.
Biopsy of Prostate (CPT code 55700): CMS will adopt the RUC-recommended work RVU of 2.50 for CY 2017. CPT code 55700 also was identified as potentially misvalued based on a screen of high expenditure screen. CMS based its decision on additional information offered by the AUA, other commenters and the recent RUC review of physician work and practice expense. The 2.50 RVU is an increase from the proposed work value from July of 2.06.
Cystourethroscopy (CPT code 52000): For CY 2017, CMS finalized a work RVU of 1.53 for CPT code 52000 despite the RUC-recommended work RVU of 1.75. This code was identified as potentially misvalued through the same screen of high expenditure services per specialty in the CY 2016 PFS final rule with comment period.
Electromyography Studies (CPT code 51784): As proposed, CMS will accept the RUC-recommended work RVU of 0.75 for CPT code 51784 and change the global period from 0-day to no global period for both CPT codes 51784 and 51785, because these codes were also identified as potentially misvalued codes based on the high expenditure service screen.
Telehealth Consultation for a Patient Requiring Critical Care Services: The AUA is pleased that CMS finalized work RVUs for new HCPCS critical care consultations codes furnished via telehealth. For CY 2017, CMS will assigned a work RVU of 4.0 to HCPCS code G0508 (Telehealth consultation, critical care, physicians typically spend 60 minutes communicating with the patient via telehealth (initial) and a work RVU of 3.86 to HCPCS code G0509 (Telehealth consultation, critical care, physicians typically spend 50 minutes communicating with the patient via telehealth (subsequent)), as proposed.
Medicare Shared Savings Program: CMS finalized the proposal to modify the EHR quality measure (ACO#11) to align with the Advanced Alternative Payment Model (APM) criteria under the Quality Payment Program. The AUA’s comments on the 2016 PFS proposed rule urged CMS to broaden the focus of the measure beyond primary care physicians to all physicians participating within an ACO, including specialists. CMS will modify the title and specifications for the measure to remove reference to primary care providers.
Conversion Factor: For 2017, CMS finalizes a conversion factor (CF) of $35.8887, an increase from the current CF of $35.8043. The final CF for 2017 reflects a budget neutrality adjustment of 0.013 percent, the 0.5 percent update factor specified by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and a 0.07 percent adjustment due to the non-budget neutral multiple procedure payment reduction (MPPR) for the professional component of imaging services, and the required -0.18 percent target recapture amount.
Estimated Impact of Medicare Expenditures for Urology Services: For 2017, CMS determined the overall impact on payment rates for urology services based on physician work, practice expense and malpractice relative value units (RVU) changes to be -2 percent (Table 52). However, the actual impact of total Medicare revenues on an individual urology practice will differ based on annual changes in RVUs, patient volume and mix of services, sequestration and any other penalties imposed from Meaningful Use and the Physician Quality Reporting Program (PQRS). To learn more about how the final rule will affect reimbursement rates for the most frequently performed urology services, view the conversion tables:
CY 2017 Identification and Review of Potentially Misvalued Services: Section 3134(a) of the Affordable Care Act requires the Secretary of Health and Human Services to periodically identify potentially misvalued services and to review and make appropriate adjustments to the relative values for those services. Under the Achieving a Better Life Experience Act of 2014 (ABLE), Congress set a target for adjustments to misvalued codes in the fee schedule for 2016, 2017, and 2018. The target was one percent for 2016, and will be 0.5 percent for 2017 and 2018. If the net reductions in misvalued codes in 2017 are less than 0.5 percent of the total revenue under the fee schedule, a reduction equal to the percentage difference between 0.5 percent and the percent of expenditures represented by misvalued codes reductions must be made to all PFS services. In the rule, CMS finalized misvalued code changes that achieve 0.32 percent in net expenditure reductions. Since these changes do not meet the misvalued code target of 0.5 percent, the annual PFS update must be adjusted by 0.18 percent as noted above.
CMS will accept comments on the final rule for 60 days. Payment rates and policies in the final rule will take effect on January 1, 2017 and will appear in the November 15, 2016, Federal Register. In the interim, the final rule is available for download. The AUA will further analyze the rule and prepare formal comments. If you have questions about the final payment rates or policy changes, please contact the AUA at R&R@auanet.org.