September 14, 2026

Submitted via Regulations.gov

Mehmet Oz, MD
Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

RE: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies: CMS-1848-P

Dear Dr. Oz:

The American Urological Association (AUA) appreciates this opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) 2027 Medicare Physician Fee Schedule (MPFS) Proposed Rule (the “Proposed Rule”).

The AUA is the leading advocate for the specialty of urology and all its subspecialties. The AUA has more than 24,000 members throughout the world. Our members represent the world’s largest collection of expertise and insight into the treatment of urologic disease. Of the total AUA membership, more than 17,000 are based in the United States and provide invaluable support to the urologic community by fostering the highest standards of urologic care through education, research, and the formulation of health policy.

Additionally, the AUA operates the AUA Urology Quality (AQUA) Registry. Developed in 2014, the AQUA Registry is a national Qualified Clinical Data Registry (QCDR) designed to measure, report, and improve healthcare quality and patient outcomes. It is unique in providing urology-specific quality measures, which enables participants to track clinical outcomes, procedural safety, and guideline adherence across important conditions like prostate cancer, bladder cancer, stones disease, and urinary incontinence. The measures provide over 2,000 registry participants with tools to identify areas for improvement, continuously refine clinical practice, and ensure patients receive the best possible care. It is also used by academic medical centers for quality tracking and improvement activities, and to support longitudinal research studies on patient health. The ability to measure and report urology-specific quality metrics is essential to delivering high-value, patient-centered urologic care.

I. Executive Summary

A. Proposed Updates to Medicare Fee for Service Payment Rates

1. The AUA encourages CMS to work with Congress to address the conversion factor, which has contributed to the steady and unsustainable decline in physician pay that ultimately harms
2. The AUA urges CMS to collaborate with our organization and other medical specialty societies prior to making the proposed changes to the global surgical package policy, which are based on inaccurate and unsupported assumptions.
3. The AUA strongly opposes CMS’s proposed changes to practice expense (PE) methodology, which removes the indirect practice cost index (IPCI) from the physician payment formula. The proposal does not provide any evidence that doing so will result in more accurate reimbursement across This is being done without consideration for the real-world impact this would have on practice sustainability and patient access to specialty care.
4. The AUA thanks CMS for accepting the RUC recommended RVUs of 90 for CPT code 90912, and 0.50 for CPT code 90913 but urges CMS to adopt the RUC-recommended work RVU of 0.80 for new code 5XX14.
5. AUA supports reconsideration of CPT code 51715 at the upcoming September RUC meeting, which does not require a referral from CMS.
6. The AUA strongly supports CMS reinstating payment for consultations to ensure physicians are adequately paid for their special expertise and significant level of effort required to care for patients with challenging, complex, and novel medical needs.
7. The AUA strenuously opposes CMS’ proposed reduction in payment for same-day services provided by the same physician because it is not evidence based and based on faulty assumptions. The reductions will result in economic harm to physicians and negatively impact practice sustainability.
8. The AUA objects to deleting HCPCS code G2211 and replacing it with a modifier, due to a lack of available evidence. It is also unlikely that doing so will reduce administrative burden.
9. The AUA supports the current role and processes of the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel and the AMA’s Resource Based Relative Value Scale Update Committee (RUC).

B. Proposed Changes to the Quality Payment Program

1. The AUA strongly opposes CMS’ proposal to sunset traditional MIPS beginning with the 2029 performance period and urges CMS to maintain the traditional MIPS pathway until at least 2032 to ensure a meaningful QPP reporting experience for MIPS eligible clinicians with measures relevant to the care they
2. With the exception of one measure that AUA is retiring, the AUA strongly opposes CMS’s proposed removal and modification of measures in the Urology MVP. Removing these measures reduces meaningful measure choice for urologists, increases reporting burden, and disadvantages clinicians whose patient populations do not support reporting on the remaining The AUA also opposes proposed modification of measures without consent of the AUA, which maintains the measures as intellectual property.
3. The AUA does not support CMS’s proposed designation of core measures for the Urology MVP. The measures do not provide meaningful options across urology subspecialties and were selected without sufficient specialty input.
4. The AUA supports proposed modifications to improvement activities in the Urology MVP as the modifications strengthen the set of improvement activities within the Urology MVP.
5. The AUA strongly opposes CMS’ proposed core measure requirements, as requiring specific measures reduces the flexibility that MVPs were designed to provide and may force clinicians to report measures that are not relevant to their patient
6. The AUA supports CMS’s proposal to remove the high-priority measure designation, because the designation limits flexibility and forces clinicians to report measures that may not be clinically relevant to them.
7. The AUA objects to making the existing and newly proposed Electronic Prior Authorization measures mandatory in 2028 and urges CMS to delay doing so until the necessary technology and payer infrastructure are broadly available and functioning.
8. The AUA strongly opposes CMS’s proposal to prohibit QCDRs and qualified registries from modifying their qualified postings after CMS should instead permit limited, documented updates so registries can accommodate normal business processes, correct errors, and ensure publicly available information remains accurate and current.
9. The AUA supports CMS’s proposal to use the most current and accurate available data source, rather than specifying PECOS, to determine eligibility for automatic Extreme and Uncontrollable Circumstances policies, because this flexibility will help ensure affected clinicians receive appropriate reporting relief.
10. The AUA supports CMS’s proposal to remove the one-year delay in public reporting for newly introduced Improvement Activities and Promoting Interoperability measures in an MVP because it promotes timely transparency and consistency in public reporting across the QPP.

II. Comments and Recommendations

A. Fee For Service Proposals

1. Conversion Factor for CY 2027

The annual pattern of cuts to physician payment and repeated fluctuations in the conversion factor creates instability and threatens the sustainability of independent medical practices. It also contributes to consolidation of medical practices which exacerbates workforce shortages thereby limiting patient access to medically necessary care, particularly in rural and medically underserved areas. The AUA calls upon CMS to collaborate with physicians and Congress to reverse this trend, establish a permanent statutory fix for the conversion factor, and prevent further harm.

There are two separate conversion factors for CY 2027: $33.17 for those participating in Advanced Alternative Payment Models (APMs), and $32.64 for everyone else. These rates reduce the conversion factor for APM participants by 1.19% and for everyone else by 1.68%. These reductions include the statutory updates of 0.75 percent for qualifying participants, 0.25 percent for non-qualifying participants and the expiration of the 2.5% statutory increase to the conversion factor that expires at the end of CY 2026. The reductions in payment are unsustainable for physicians and ultimately hurt patients.

While the AUA understands that CMS is constrained by statutory requirements in establishing the yearly conversion factors, the flat rates underscore the continued instability of the MPFS and the need for a permanent, predictable approach to updated Medicare physician payments. Without stable, predictable updates to the conversion factor, it remains difficult for urology practices, particularly independent and rural practices that CMS purports to support, to absorb rising costs associated with maintaining staff, purchasing medical supplies and equipment, investing in new technology, and meeting administrative requirements. When adjusted for inflation in practice costs, Medicare physician payments have decreased by 33 percent.¹ This trend is unsustainable.

Unlike other Medicare payment systems, the MPFS does not provide physicians with a routine inflationary update that adequately reflects increases in the cost of delivering care to Medicare patients. The AUA remains concerned about the impact of this volatility on practices’ ability to do financial forecasting, confidently staff their practices, procure the resources they need to care for their patients, and effectively manage their revenue cycles. Ultimately, this affects patient access to urologic services.

Of particular concern for the AUA is the cumulative effect of the proposed conversion factor reductions and other policies proposed in this rule will reduce reimbursement for the specialty of urology. CMS estimates that reimbursement for urology will decrease by two percent based on the policies in the proposed rule. Specifically, proposed changes to the indirect practice expense calculation and for services billed using modifier -25 will create additional downward pressure on Medicare reimbursement, potentially threatening Medicare patients’ access to care. We urge CMS not to implement policies that will create additional downward pressure on Medicare reimbursement for physician services.

2. Global Surgical Packages

The AUA encourages CMS to collaborate with medical specialty societies to craft evidence-based policy that adequately and fairly reimburses physicians for the care they provide to patients during the post-operative period.

There is nothing to support CMS’s assertion that post-operative E/M services are over-valued. CMS’s unsupported supposition regarding the nature of post-operative visits is inaccurate. The AUA sought feedback from the members of the AUA’s Payment Policy Reimbursement Committee (PPRC), and those members consistently report that they will often provide more post-operative care than is accounted for in current global urological surgical packages, contrary to CMS’s belief that many post-operative visits are not provided. If CMS suspects that surgical services are overvalued, then CMS should resolve its own misvalued code identification process. The AUA welcomes the opportunity to engage with CMS on developing appropriate evidence for evaluating codes that it suspects may be misvalued.

3. Updates to Practice Expense Methodology

The AUA opposes the removal of the indirect practice cost index (IPCI) from the payment rate formula.

The Proposed Rule would eliminate use of specialty-specific survey data used in the indirect practice expense index. There is no evidence that this is necessary, that the Indirect Practice Cost Index (IPCI) is unreliable, invalid, or that it distorts code level valuations. Rather, specialty-specific practice expense per hour data is the best available data to inform indirect practice expenses and final P/E RVUs.

There are two important points to consider. First, the purpose of the IPCI is to establish payment amounts that more accurately reflect the costs of furnishing services, including differences related to specialty type. Second, CMS has access to updated data that could be incorporated into the methodology, specifically the data from the AMA Physician Practice Information Survey (PPIS). At a minimum, CMS should model the impact of incorporating the updated AMA PPIS data and make those results available for public review and comment. By declining to use the updated empirical evidence available to agency, CMS is disregarding the type of information needed to support a fair and balanced payment system, while also failing to provide its own data as an alternative. Eliminating a portion of the payment formula without supporting evidence will not improve the accuracy of physician payment or ensure that payments reflect “the resources required to furnish individual services.”

The AUA opposes the implementation of any further changes that reduce physician payment. CMS should maintain the IPCI portion of the PE RVU calculation formula until it assesses the impact of the significant change made in 2026 and has evidence demonstrating another revision is necessary. Although CMS has expressed concerns with the existing data, it has not identified a better set of specialty-derived practice cost data.

CMS continues to make arbitrary changes to the physician payment formula without consideration for the real-world impact these policies have on practice sustainability or patient access to specialty care. The AUA encourages the agency to reconsider proposed policies that are not grounded in facts and empirical data to support it.

CMS also seeks comments on potential approaches to better identify hospital-employed physicians, including whether a new HCPCS modifier could distinguish services furnished by employed clinicians and allow more accurate allocation of indirect practice expenses. The AUA supports the creation of modifiers to identify hospital employed physicians. This would enable CMS to apply the indirect PE reduction only to those physicians who do not have separate administrative or clinical offices. Applying the indirect practice expense payment cut across the board is not an appropriate means to control Medicare spending. Using a modifier would potentially be a more measured and fair approach. If CMS proposes to adopt a modifier in lieu of the current allocation method, CMS should first share specific specialty-level impact analysis in proposed rulemaking and allow for comment.

4. Valuation of Specific Codes

Prostate Biopsy Services (CPT codes 55705, 55707, 55708, 55709, 55710, 55711, 55712, 55714, and 55715)

The AUA thanks CMS for proposing the RUC-recommended values for all but one code in this family and urges CMS to finalize those values. However, the AUA recommends that CMS adopt the RUC-recommended work RVU of 0.80 for new code 5XX14 (Biopsy, prostate, transrectal or transperineal, including imaging guidance, fusion-targeted lesion(s) without regional; each additional targeted lesion (List separately in addition to code for primary procedure).

The AUA was instrumental in revising the prostate biopsy codes to reflect current clinical practice for prostate biopsy services after two codes, 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) and 76872 (Ultrasound, transrectal;) were referred to the CPT Editorial Panel for revisions. The AUA is grateful that CMS has accepted the RUC reaffirmed work values and PE inputs for all codes associated with the prostate biopsy CPT code family.

However, CMS did not support the RUC-recommended work RVU of 0.80 for new code 5XX14 and instead proposes a work RVU of 0.68. CMS reduced the proposed value by crosswalking 5XX14 to CPT code 93567 (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography). CPT code 93567 is an inappropriate comparator for 5XX14 and does not accurately reflect the physician work or the intensity of this service.

CPT code 5XX14 is an add-on code used in conjunction with CPT code 55711 Biopsy, prostate, transrectal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion (work RVU = 2.61, 20 minutes intra-service time and 62 minutes total time) for each additional targeted lesion. An add-code to report each additional fusion-targeted lesion without regional, did not exist in the prior code structure. This add-on code differs significantly from its predecessor code, and the change from former CPT code 55712 to CPT code 5XX14 was not merely editorial.

CMS's proposed work RVU of 0.68 for CPT code 5XX14 would create a rank order anomaly within the code family. While we understand CMS’s concern about the discrepancy in intensity between CPT codes 5XX14 and 55715, it is not atypical. Measurements of intensity across small amounts of time data tend to show wider fluctuation, making it difficult to make robust comparisons. The AUA maintains that these intensity levels are appropriate and accurate given the physician work described and the intensity and complexity of that work. The AUA supports the RUC survey result of the 25th percentile work RVU of 0.80 for CPT code 5XX14. This value maintains relativity within this code family and across similar services. We recommend that CMS finalize the RUC-recommended work RVU for CPT code 5XX14.

Biofeedback Training (CPT codes 90901, 90X03, 90912, and 90913)

AUA is grateful that CMS has accepted the RUC recommended RVUs of

0.90 for CPT code 90912 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient), and 0.50 for CPT code 90913 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)0. CMS also proposed accepting all practice expense inputs recommended by the AMA RUC. We urge CMS to finalize the values for CPT codes 90912 and 90913 as proposed.

5. Potentially Misvalued Services Under the Physician Fee Schedule

Urethral Bulking (CPT Code 51715) (Endoscopic injection of implant material into the urethra and/or bladder neck)

AUA supports reconsideration of CPT code 51715 at the upcoming September RUC meeting, which does not require a referral from CMS.

CPT code 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) was nominated as potentially misvalued. According to the nominator, the current non-facility valuation does not include the urethral bulking agent needed to perform the services in the office setting. CMS proposes to create a new direct practice expense supply code SD396, representing a 2 mL vial of urethral bulking agent, priced at $1,175 and to include one unit of this supply in the non-facility practice expense inputs for CPT code 51715.

CPT code 51715 has already been identified by the RUC’s RAW on the high-volume growth screen and an action plan will be reviewed at the September 2026 RUC meeting to determine whether the code should be re-reviewed. Therefore, any action that CMS would take in this rulemaking cycle would be duplicative of the consideration already underway. The AUA recommends that CMS not take any action until the RAW’s review of the action plan is complete.

6. Payment for Primary Care and E/M Services

The AUA recommends that CMS reinstate payment for the outpatient consultation CPT codes 99242-99245.

The AUA appreciates CMS’s interest in better distinguishing between longitudinal, acute, and consultative care. These categories meaningfully reflect different medical services and patterns of care, which should be appropriately recognized by the MPFS. Urologists frequently provide true consultative care when another physician requests their expertise to evaluate a clinical problem and recommend an appropriate course of action. Consultative visits require significantly more work than a standard new patient visit requiring the review of extensive medical records, laboratory and pathology reports, and operative notes; the synthesis of complex information; patient counseling; the formulation of recommendations including a formal report; and communication with the referring provider.

The following clinical example illustrates the work of a urologic consultation and highlights how this care is distinguished from an acute or longitudinal care encounter:

A 62-year-old male is referred by his primary care physician for an elevated PSA of 5.2. The patient also complains of nocturia X 2, somewhat slow stream, and feeling of incomplete emptying. The patient has Type 2 diabetes mellitus, hypertension, and morbid obesity with sleep apnea. The consultation involves the review of outside labs (PSA history/trends, metabolic panel, A1C, glucoses) and prior imaging along with obtaining baseline IPSS.

• Reviewing any prior imaging and labs
• Obtaining a focused urologic history (family history of prostate cancer, LUTS, prior biopsies, IPSS)
• Performing a physical exam
• Counseling extensively on the significance of elevated PSA, differential diagnosis, role of multiparametric MRI, biopsy options (systematic vs. MRI-fusion targeted), risks of biopsy, and the possibility of active surveillance vs. treatment if cancer is found. Discussing LUTS and the role of BPH, diabetes on various aspects and possible treatment options and options for further testing once cancer is ruled Discussing the role of sleep apnea and nocturia.
• Ordering an MRI
• Generating a detailed consultation letter to the PCP with assessment and plan

The defining feature of these visits is not simply that the patient is new to the urologist. Rather, another clinician is seeking the urologist’s specialized expertise to answer a clinical question, establish or refine a diagnosis, assess treatment options, and provide recommendations that will inform the patient’s subsequent care. Medicare’s current E/M coding structure does not adequately recognize this distinction. CMS discontinued payment for consultation services in 2010 and generally requires physicians to report new or established patient outpatient E/M codes for services that would otherwise meet the criteria of a consultation. As a result, the coding structure does not clearly identify or recognize the distinct role a physician performs when providing consultative care.

As CMS considers how to distinguish between longitudinal, acute, and consultative care, the AUA encourages the Agency to recognize the consultation as a distinct category of physician services, again, by reinstating payment for the existing outpatient consultation codes (CPT codes 99242-99245). Doing so would align Medicare payment policy with the distinctions CMS itself is exploring through this request for information and would more accurately recognize the specialized expertise, clinical decision-making, and physician-to-physician communication inherent in consultative care.

7. Proposed Changes to Payments Using Modifier - 25

The AUA strenuously opposes the 50% “same-day service” reduction proposed by CMS, which is based on faulty, unsupported assumptions that efficiencies are achieved when doing a procedure on the same day as E/M services, warranting this drastic payment cut.

CMS cites no evidence other than its “belief” that “we are likely duplicating payment”² when performing a surgical procedure on the same day as E/M services. A payment cut of this magnitude should be based on a thoughtful analysis of empirical data provided by or validated in consultation with physicians in the surgical specialties.

There are many instances for both patient convenience and timely care when procedures and E/M services are appropriately performed on the same day. The E/M and the procedure represent distinct, separately identifiable services with minimal overlap. A 50% reduction to either service is arbitrary and capricious and violates the basic tenet of fair pay for services performed.

Urologists routinely care for patients with complex conditions where a procedure is necessary for evaluation or treatment but represents only part of the physician’s overall work. The physician may need to evaluate comorbidities, establish a differential diagnosis, determine the appropriate treatment, or coordinate care with another physician. These activities are a portion of the total E/M service and should not be considered incidental simply because a procedure is performed during the same patient encounter.

The AUA compared the direct practice expense inputs for two services commonly performed together:

CPT code 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded), and CPT code 52000 (Cystourethroscopy (separate procedure)).

Publicly available direct practice expense input files were used to compare the practice expense inputs for these two services. The analysis showed that, if the office visit and procedure are performed in the same room, the only direct expense practice expense inputs that are duplicative are a single sanitizing wipe ($0.07) and three minutes of LPN time (at $0.54/minute). If the procedure is performed in a separate, dedicated procedure room, and not in the same room where the E/M services were performed, then there is zero duplication of direct PE inputs.

The empirical evidence gathered from CMS’s own published data files proves that a 50 percent payment reduction to either one of these services is not justifiable based on CMS’s unsupported assumption of “likely resource overlap.”

Not only do the practice expense inputs not overlap enough to justify a 50 percent reduction, neither does the physician work and time needed to perform both procedures. To assume that both the E/M service and the procedure could be performed in the same allotted time is not clinically feasible or appropriate.

The AUA has provided additional examples illustrative of patient care encounters that include both an E/M service and procedure occurring regularly in a urologist’s practice. These examples were obtained from members of the AUA’s PPRC to show the varying types of same-day procedures that are preceded by an E/M service. The AUA’s review of the resources required for the procedures and the same-day E/M service confirm there is little to no overlap.

• Stress urinary incontinence: A patient presents six months post-prostatectomy with stress urinary incontinence. Patient’s history is evaluated, and severity of incontinence is reviewed as are prior treatments, patient goals, and a complete physical examination is performed. A cystoscopy (CPT code 52000) is performed to determine the cause of the incontinence.
• Unexplained incontinence: Patient’s history is evaluated, and severity of incontinence is reviewed as are prior treatments, patient goals, and a complete physical examination is performed. A complex cystogram (CPT code 51726) is performed to determine cause of symptoms.
• Gross hematuria/clot retention: Patient presents emergently to the urology clinic with blood in urine. E/M is performed, and decision made to proceed with catheter placement for bladder irrigation (CPT code 51700).
• Urinary retention due to urethral stricture: Patient presents emergently with painful urination. E/M is performed, and a decision is made to perform urethral dilation (CPT code 53600) with complex catheter placement.

The AUA strongly urges CMS to withdraw the arbitrary, and capricious “same-day service” proposal and instead explore the validity of its suspicion that there may be potential practice expense overlap, through evidence. At a minimum, CMS should establish at the individual code level of any assumed resource overlap existing for the services subject to the policy. Payment adjustments should be supported by evidence of actual resource efficiencies, rather than an assumption that services furnished on the same day require substantially fewer resources. As demonstrated by the example of CPT codes 99204 and 52000, services performed on the same day do not necessarily result in meaningful reductions in the resources required to furnish either service.

Additionally, the AMA RUC valuation methodology is specifically structured to account for and exclude physician work and practice expense overlaps when a separately identifiable E/M service is reported with modifier -25. CMS has historically recognized the validity of this methodology, accepting more than 90 percent of RUC-recommended work, practice expense, and malpractice RVUs for inclusion in the MPFS. It is therefore difficult to understand why CMS now asserts, without empirical evidence, that the existing process does not adequately account for practice expense overlaps.

Finally, it is unreasonable to expect a physician to send a patient home without performing a procedure that is clinically necessary. When services that are medically necessary and furnished during the same encounter, the encounter then reflects appropriate, patient-centered care and should not be presumed to involve duplicative resources.

8. Revision of G2211 with Modifier MOD1

The AUA urges CMS to maintain existing add-on code G2211 and the associated RVUs rather than replace it with MOD1 beginning in CY 2027.

CMS established G2211 to recognize the additional resources associated with outpatient E/M visits that are part of an ongoing longitudinal relationship with a Medicare patient. Urologists have appropriately incorporated this add-on code into their practices to reflect the additional work associated with providing this type of care, and urology accounts for approximately six percent of the service’s utilization based on publicly available claims data.

Under the proposed policy, replacing G2211 with MOD1 would increase payment for the underlying E/M service by 16 percent rather than a flat add-on payment of approximately $17. While this approach would result in a modest increase in reimbursement for higher level E/M services, this increase would be offset by eliminating the 0.33 work RVUs currently associated with G2211. The loss of these work RVUs has significant implications beyond the Medicare payment amount for the individual encounter. Many urologists employed by hospitals, health systems, and large group practices are evaluated and compensated, in whole or in part, based on their productivity as measured by work RVUs. Eliminating G2211 and its associated work RVUs would make it more difficult for those physicians providing a significant amount of longitudinal care to meet their productivity expectations even when Medicare payment for the underlying encounter remains similar or increases slightly.

Furthermore, CMS has not established a sufficient basis for fundamentally restructuring G2211. The add-on code was only recently implemented in CY 2024; there is only one full year of publicly available data on its utilization. CMS should delay further evaluation of G2211 until there is sufficient publicly available utilization data suggesting a need for change.

The AUA also questions whether replacing an add-on code with a new modifier will meaningfully reduce administrative burden. Physicians and their practices will still need to determine if an encounter meets CMS’s billing requirements, which would remain unchanged, and append the modifier to the claim. Changing the mechanism for reporting will not eliminate that determination, and practices will be required to update billing systems and workflows to accommodate the change. Therefore, the AUA urges CMS not to finalize this policy, and instead, collect three years (minimum) of utilization data before considering fundamental changes to the code’s structure or valuation. This would allow CMS to evaluate whether proposed changes to G2211 will achieve their intended purpose and work with physician stakeholders to better understand the implications of any proposed changes.

9. Current Procedural Terminology Request for Information

The AUA supports the current role and processes of the AMA CPT Editorial Panel and the AMA RUC. These processes are invaluable to the Medicare payment system because they bring the perspective of physicians and other health care professionals directly into the development and valuation of physician services. There is no better source for understanding how care is delivered than the clinicians who provide that care. The CPT process establishes a structured framework for defining and reporting services, while the RUC process provides a rigorous mechanism for evaluating the resources required to furnish those services. Together, these processes help ensure that changes in medical practice and the services provided to patients are reflected in the Medicare Physician Fee Schedule.

The CPT and RUC processes also include substantial safeguards that help maintain the integrity of the valuation process. Establishing a new CPT code and obtaining a valuation recommendation requires meeting established criteria and navigating a rigorous review process. Recommendations are subject to review and scrutiny by physicians from other specialties, creating an important check and balance system. This specialty-to-specialty review is an important feature of the process and helps promote appropriate valuations across the physician fee schedule while ensuring that relativity, the foundation of the MPFS, is maintained.

The processes also provide significant value to CMS and, ultimately, taxpayers. Physicians and other stakeholders contribute substantial time and expertise to the development and review of codes and valuations, allowing CMS to draw on clinical expertise without having to independently recreate these processes and incur the associated costs of managing the processes. Since the inception of the Relative Based Relative Value Scale (RBRVS), CMS has relied on the RUC process to recommend MPFS service code valuations. It is commonly known that, year after year, CMS accepts approximately 90 percent of the RUC recommended work RVUs for each new or revised service. This acceptance rate proves that CMS relies on the valuable input of physicians through the CPT and RUC processes.

Additionally, CMS has not proposed a viable alternative or structure to replace the CPT and RUC processes. We encourage CMS to seek expert guidance from medical specialty societies, such as the AUA, while it continues to explore alternative pathways. Until such time there is a viable and superior alternative that includes the input of physicians and other relevant stakeholders, the AUA will continue to support and participate in the established CPT and RUC pathways. We reiterate that any changes to this process should preserve the current strengths and recognize the value of a system that is grounded in the experience of physicians who provide care.

B. UPDATES TO THE QUALITY PAYMENT PROGRAM

1. Proposed Sunset of Traditional MIPS

The AUA strongly disagrees with CMS’ proposal to sunset traditional MIPS and urges CMS to delay elimination of traditional MIPS until at least 2032 to ensure a meaningful QPP reporting experience for MIPS eligible clinicians with measures relevant to the care they provide.

Currently, there are insufficient measure choices within MVPs for all MIPS eligible clinicians, which disproportionately affects subspecialties. Further analysis is required to better understand if the current MVP inventory is truly sufficient to warrant a move towards mandatory MVP adoption. It is likely that subspecialties have more limited choice than others (because fewer measures apply to them), putting them at a potential disadvantage. In the CY 2027 Proposed Rule, CMS states that “a small number of MIPS eligible clinicians voluntarily reported MVPs during those three performance periods [2023 through 2025].” This trend is concerning, given that CMS has stated it believes that the MVP reporting option should reduce burden. Before moving towards mandatory MVP adoption, CMS should take action to better understand why MIPS eligible clinicians are not opting into MVP reporting and how to support and incentivize greater specialty participation.

Stability in program requirements is critical at this time. Congress is exploring legislative action to address some of the pitfalls evident in the Quality Payment Program (QPP). The AUA supports Congressional efforts to replace MIPS with a more clinically meaningful, specialty-supported approach to quality measurement and physician payment. CMS should refrain from making significant changes to MIPS at this time and should instead maintain program stability, given the added burden and confusion any significant changes may make, while Congress considers action regarding the future of the QPP.

Until CMS recognizes the barriers to MVP reporting and can ensure meaningful, specialty-relevant measures exist for reporting via the MVP pathway, CMS should maintain the traditional MIPS pathway. If CMS decides to eliminate the traditional MIPS pathway, it should delay the MVP mandate for at least five years until 2032 to give specialty societies time to draft new MVP pathways and for physicians to make changes necessary to maintain quality scores that will support sustainable practice. A five-year implementation timeline also will provide time for measure developers, including QCDRs, to develop alternate measures. AUA encourages CMS to explore additional incentives to encourage MVP adoption so that more clinicians elect voluntary MVP adoption in the meantime.

In the event CMS eliminates the traditional reporting option, CMS should provide the AUA and other specialty societies and QCDRs clarity on how new measures will be introduced into the Quality Payment Program for reporting year 2027, given that measures must currently be in the program for one year before they can be added to an MVP.

2. Proposed Urology MVP Measure Removal and Modifications.

Except for the measure that AUA is retiring, the AUA strongly disagrees with the proposed removal and modification of measures in the Urology MVP, particularly given the lack of collaboration with the AUA and other relevant stakeholders. The AUA urges CMS to maintain consistency in the Urology MVP wherever possible until more eligible clinicians have reported on the MVP.

The table below summarizes the positions of AUA, the AQUA Registry, and its participants on CMS’ proposals related to measures in the Urology MVP, “Optimal Care for Patients with Urologic Conditions.” (Urology MVP)

Table X. Optimal Care for Patients with Urologic Conditions MVP Proposed Changes and AUA Position

Measure #	Measure Title	CMS Proposed Action (rationale)
Opposed to Removal
AQUA8	Hospital Admissions or Infectious Complications Within 30 Days of Prostate Biopsy	Remove (high performing)
AQUA15	Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures	Remove (process measure); modify if retained.
AQUA16	Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 Disease	Remove (low adoption, no benchmark after 2 consecutive years in MIPS)
Opposed to Proposed Revision
MUSIC4	Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients	Modify
AUA Supports Removal Due to Planned Retirement
AQUA14	Stones: Repeat Shock Wave Lithotripsy Within 6 Months of Initial Treatment	Remove (high performing), modify if retained

 

In general, the AUA, the AQUA Registry, and its participating practices and physicians fervently disagree with CMS’ proposed changes to the Urology MVP. Regardless of whether CMS eliminates traditional MIPS in favor of mandatory MVP reporting, removing specialty-specific measures from the Urology MVP will reduce urologists' ability to report on measures that are relevant to their practices and demonstrate improvement in urological care. When clinically meaningful specialty measures are removed, urologists may be forced to report measures that are less applicable to the care they provide, increasing reporting burden without improving the value for quality improvement purposes. If measures are removed as proposed, clinicians may ultimately find that they are unable to report on four measures given their patient population, likely negatively affecting their overall score and potentially resulting in disproportionate payment penalties for clinicians with limited choice.

The AUA and AQUA Registry oppose the modification or removal of measures without appropriate, meaningful engagement with relevant stakeholders, including measure developers, above and beyond the opportunity to submit public comments. The current Urology MVP—with its inclusion of 5 QCDR measures—is almost identical to the draft submitted to CMS by the AUA and others, which included specialty-specific measures selected through a consensus-based process designed to identify measures that are clinically meaningful and appropriate for urologists. The proposed removal of the QCDR measures deemed relevant by representatives from the field disrespects the care and expertise of the urologists and other experts who contributed to the consensus-based work.

Further, CMS’s proposed modifications would result in a derivative of the AUA-developed and AUA-owned measures included in the Urology MVP. While the AUA welcomes CMS’ input into AUA’s measure specifications, the AUA did not and does not consent to CMS using or modifying AUA’s intellectual property without a license. The AUA requests a meeting with CMS to discuss this matter further.

The AUA strongly encourages CMS to avoid removing measures from MVPs, including the Urology MVP, because adoption is low, and a benchmark is not available, or the measure performance is high. In order to prioritize stability and because AUA expects that more clinicians will report these measures over time due to their inclusion in MVPs (and performance may well look different with broader adoption), the AUA urges CMS to retain these measures.

CMS’s proposal to remove AQUA QCDR measures from the Urology MVP because they lack benchmarks, have low adoption, or show high performance is extremely curious, since CMS also is proposing to designate several measures that are topped out or do not have a benchmark as core measures. CMS has offered no explanation for this inconsistency and thus AUA requests that CMS provide its rationale. Trust, confidence, and participation in the Quality Payment Program depends on the fair, consistent, and predictable administration of CMS policy and rationale, especially by the specialty societies that carry the burden and expense of the unfunded mandate to develop measures so their members can participate in the QPP.

The AUA and the AQUA Registry offer the following specific comments to CMS’ proposed changes to the measures in the Urology MVP.

AQUA8 - Hospital Admissions or Infectious Complications Within 30 Days of Prostate Biopsy

AUA strongly opposes removal of this outcome measure and urges CMS to retain it in the Urology MVP, because, as more clinicians report the measure, performance will look differently.

Although CMS proposes removing the measure because it is high performing, AQUA 8 is currently underutilized and performance will vary with broader adoption. AUA has observed performance across the broader AQUA Registry, which indicates that an important opportunity for improvement remains. The registry-wide rate is approximately 4 to 5 percent₃, demonstrating that adverse outcomes following prostate biopsy continue to occur in clinical practice and, accordingly, continued reporting is necessary to validate quality improvement.

AQUA15 - Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures

AUA strongly opposes removal of this measure and urges CMS to retain AQUA15 in the Urology MVP because it addresses an important clinical area, although it is a process measure. The AUA furthermore opposes any modification to the measure that is outside of the measure development and update process established by the measure developer/intellectual property holder.

Available performance data for this measure demonstrates a substantial quality gap. The 2025 registry-wide performance rate was only slightly above 50 percent₄, indicating that adherence to this important clinical action is far from universal. Patients will benefit from greater adherence to this clinical practice.

The AUA also opposes CMS’s proposed modifications to this measure. AUA recognizes the importance of addressing abnormalities that are identified through the testing process. However, electronically capturing a quality action associated with this measure remains challenging because of inconsistent use of standardized terminology such as LOINC and SNOMED and because relevant information is contained in unstructured clinical notes or external documents that are not available through current EHR data extraction.

Further, this measure is the intellectual property of the AUA and CMS has not obtained a license to create derivative work by mandating a modification. AUA intends to revisit opportunities to enhance AQUA15 as healthcare taxonomies, interoperability, and electronic extraction capabilities improve.

AQUA16 - Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor for T1 Disease

AUA opposes removal of this measure and urges CMS to retain it in the Urology MVP because of its clinical importance and the likelihood of increased adoption as more urologists elect MVP reporting.

Repeat TURBT for appropriate patients with T1 disease is clinically important because repeat evaluation can identify residual disease or upstaging that may materially affect subsequent treatment decisions. Repeating TURBT in patients with T1 disease is strongly recommended in the AUA/SUO guideline ₅ because it provides important diagnostic, prognostic, and therapeutic information.

Disease under-staging following an initial TURBT is well documented, and repeat resection can identify patients whose disease has progressed into the muscularis propria and who therefore require substantially different treatment. The AUA/SUO guideline notes that upstaging to muscle-invasive disease has historically been reported in approximately 30 percent of patients with T1 tumors and can occur even when muscularis propria was present in the initial specimen. In addition, substantial residual disease may be identified at repeat resection, and residual T1 disease is associated with a particularly high risk of subsequent progression. More contemporary evidence continues to demonstrate clinically meaningful rates of residual disease and under-staging. These findings demonstrate that repeat TURBT is not simply a duplicative procedure, but an important opportunity to ensure accurate staging and guide appropriate subsequent treatment.

Lack of a benchmark in this measure is not an adequate basis for removal from the Urology MVP. Like all of AUA’s AQUA measures, AQUA16 is a specialty-specific measure endorsed for the Urology MVP through a consensus-based process to gauge and encourage quality improvement in an area of need that has not yet been broadly reported. Low adoption, particularly during a period of limited MVP participation, does not mitigate the need to measure quality of care in patients with T1 disease. Retaining AQUA16 within the Urology MVP will allow for increased adoption. Benchmark feasibility can be reassessed as participation expands.

Moreover, retaining this measure advances CMS' broader goal of measure alignment, as measures assessing similar aspects of bladder cancer care are used in quality-improvement efforts outside of MIPS.

MUSIC4 - Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients

The AUA opposes CMS's proposed revision to this measure that is outside of the measure development and update process established by the measure developer/intellectual property holder.

MUSIC4 should not be modified to incorporate the confirmatory biopsy requirements addressed separately by AQUA36, Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance. More broadly, AUA objects to CMS attempting to force substantive revisions to AUA-developed measures outside of the AUA's established measure development and maintenance process. As the measure steward, AUA has a structured process for reviewing the evidence, obtaining expert and stakeholder input, assessing feasibility and unintended consequences, and determining when revisions to AUA-owned measures are warranted.

Furthermore, the AUA disagrees with the rationale for the proposed revisions. Although the two measures (MUSIC4 and AQUA36) relate to active surveillance, they assess different aspects of care and have different denominator populations. Combining the concepts would therefore be more complex than simply adding a confirmatory-biopsy requirement to MUSIC4 and would change the meaning and feasibility of a measure that is already well established.

MUSIC4 addresses an important patient-centered quality objective: avoiding unnecessary treatment and the potential adverse effects of treatment among men with low-risk prostate cancer who are unlikely to benefit from immediate intervention. The measure is widely used beyond the AQUA Registry and MIPS, including within the Michigan Urological Surgery Improvement Collaborative (MUSIC) and practices participating in its broader collaborative efforts. This alignment increases the measure's value while reducing fragmentation in quality reporting.

AQUA14 - Stones: Repeat Shock Wave Lithotripsy Within 6 Months of Initial Treatment

The AUA supports CMS's proposal to remove this measure, as the AUA is retiring this measure in response to changes in the clinical guidelines that provide the underlying basis for the measure. AUA does not intend to submit AQUA14 for continued inclusion in the QPP for the 2027 performance period.

3. Designation of Core Measures for the Urology MVP (Q050, Urinary Incontinence, Q358, Patient Centered Surgical Risk Assessment and Communication and Q462 Bone Density Evaluation for Patients with Prostate Cancer)

The AUA does not support CMS’ proposed designation of core measures within the Urology MVP, because the AUA does not support the broader concept of requiring clinicians to report a CMS-designated core measure within an MVP (as discussed in further detail elsewhere in this letter), and because CMS has identified these particular measures without consultation with the AUA and other relevant stakeholders.

MVPs were intended to provide more clinically cohesive and specialty-relevant reporting options than traditional MIPS. Requiring every MVP participant to report one of a small number of CMS-selected measures limits that flexibility and likely will require urologists to report measures that are not relevant to their patient population, scope of practice, or quality improvement priorities and thus do not advance CMS’ quality improvement goals.

The AUA is particularly concerned that CMS selected the proposed urology core measures without meaningful consultation with the AUA or the broader urology community. The three measures identified by CMS as “core measures” do not provide meaningful options for all urology subspecialties, and each applies to a relatively specific clinical circumstance.

Moreover, one of the proposed core measures is topped out and another does not have a benchmark, raising questions about their ability to identify meaningful differences in quality or opportunities for improvement. Designating  topped-out  measures  as  mandatory  core  measures is especially difficult to reconcile with CMS's proposals elsewhere in the rule to remove specialty-specific measures based on high performance, such as AQUA8.

The AUA also objects to CMS’s exclusion of QCDR measures from consideration for core-measure designation. This policy disadvantages specialty-developed measures that were specifically designed to address clinically meaningful aspects of urologic care. It is particularly problematic for CMS to require urologists participating in the Urology MVP to select a core measure while simultaneously excluding AUA-developed QCDR measures from consideration for that designation.

4. Proposed Urology MVP Improvement Activity Modifications

The AUA supports proposed modifications to improvement activities in the Urology MVP, including the addition of new improvement activities, revisions to improvement activities, and the removal of an improvement activity because its elements would be incorporated into a revised measure. These modifications strengthen the set of improvement activities within the Urology MVP.

5. MIPS Core Measure Requirements

The AUA strongly opposes CMS’s proposed core measure requirements. Requiring specific measures reduces the flexibility that MVPs were designed to provide and may force clinicians to report measures that are less than optimal to their practices or quality-improvement needs.

While the AUA appreciates CMS’s efforts to better standardize performance data, MVPs by design already include a subset of quality measures that are relevant and meaningful for the specialty or condition, which can be considered “foundational measures” for that specialty or condition. Second, over time, as MVP reporting becomes more common, sufficient comparative performance data will become available for many of the measures included in MVPs without needing to mandate reporting of specific measures.

Third, this proposed change will further complicate the MVP reporting process, make it even more confusing for participants, and discourage voluntary MVP reporting. Fourth, mandated reporting of a specific “core” measure, frustrates the goal to increase reporting on measures that are most relevant to improvement needs by eroding measure selection flexibility. This proposal will also disincentivize participation by requiring physicians and practices to collect and report on data that is irrelevant to their practices, patients, and quality improvement goals. Finally, CMS’s core measure proposal offends concepts of fundamental fairness because it disproportionally disadvantages some physicians and specialists, like urologists.

If CMS proceeds with its proposals to mandate core measure reporting, CMS should delay implementation for five years (until 2032) to work closely with relevant specialty societies and other stakeholders to designate core measures that are relevant to their practice, will not result in negative downstream implications, and will advance their quality improvement goals. CMS states that “MIPS core measures would be limited to measures that are most reflective of the care that is unique to each MVP’s specialty or medical conditions.” This intent can only be realized through meaningful collaboration between CMS and specialty societies. The AUA has a demonstrated history of successful collaboration with CMS to develop the Optimal Care for Patients with Urologic Conditions MVP through a multi-stakeholder consensus process.₆ CMS should continue this collaborative approach as the MVP is updated to ensure it continues to reflect optimal care for urology patients and remains relevant to the specialty.

Finally, AUA is compelled to question CMS’s rationale proposal to designate as “core” certain measures that currently are topped out or lack a benchmark while simultaneously proposing to remove high-performing and non-benchmarked QCDR measures from the Urology MVP. If CMS chooses to move forward with plans to include topped out measures as core measures, CMS should explore alternate scoring approaches (e.g., removing the seven-point cap) so that clinicians are not unfairly penalized for reporting these measures.

6. Proposal to Remove the High-Priority Measure Designation

The AUA supports CMS’s proposal to remove the high-priority measure designation because the designation limits flexibility and forces clinicians to report measures that may not be clinically relevant.

The designation of a measure as "high priority" does not necessarily indicate that the measure addresses a highly relevant clinical topic, the greatest gap in care, or the most meaningful opportunity for improvement within a specialty. Eliminating this designation would simplify MIPS reporting requirements and allow clinicians and specialty organizations to focus more directly on measures that are clinically relevant and meaningful to the populations they serve.

7. Electronic Prior Authorization Measure Proposals

The AUA objects to making the Electronic Prior Authorization measure for medical items and services and objects to the new Electronic Prior Authorization for prescription drugs measure mandatory in 2028, and urges CMS to delay implementation until the necessary technology and payer infrastructure are broadly available and functioning.

The AUA continues to oppose prior authorization requirements, which delay care, harm patients, create significant administrative burdens, and fundamentally interferes with the physician-patient relationship. However, if CMS insists on retaining prior authorization as a condition of reimbursement for care of Medicare patients, the agency should give deference to clinical care choices made by physicians and their patients; ensure processes are streamlined to reduce administrative burden; and remove all obstacles that delays patient care. If artificial intelligence is used in any part of the prior authorization process, it should be disclosed, validated by a physician in the same specialty, and provide safeguards against automatic denials.

The AUA objects to the proposed timeline for the electronic prior authorization for medical items and services measure to become mandatory because successful reporting will depend on the availability and implementation of certified health IT modules and functioning payer Prior Authorization APIs. These conditions are unlikely to improve across all platforms by 2028 and are largely outside the control of individual practices. CMS should condition mandatory reporting on demonstrated availability and successful implementation of these capabilities and maintain appropriate exclusions without penalty when the necessary technology or payer functionality is unavailable.

If CMS imposes a requirement to report on a new measure to evaluate the impact of prior authorization on prescription drugs, implementation should be delayed until the necessary technology and payer infrastructure are broadly available and functioning. We urge CMS to ensure that implementation is based on demonstrated readiness and to maintain appropriate exclusions without penalty for clinicians who cannot satisfy the measure because of factors outside their control.

Third Party Intermediaries General Requirements

8. Proposal to prohibit qualified posting changes.

The AUA strongly opposes CMS’s proposal to prohibit changes after the qualified posting is published as this change is not feasible given registry business processes.

CMS is proposing that, beginning in the 2027 performance year, QCDRs and qualified registries are prohibited from making changes after the qualified posting is made on the CMS website. The AUA appreciates CMS’s goal of maintaining consistent QCDR and qualified registry information. However, registry sponsors’ business processes, including approval mechanisms, may not align with CMS’s self-nomination timeline. The prohibition could also prevent correction of errors. CMS should permit limited, documented updates. CMS should require QCDRs to add a note to the qualified posting indicating the date the information was last updated and directing clinicians to contact the registry for the most current information. This approach will achieve the related goals of consistency, recency, and accuracy.

9. Expanding Extreme and Uncontrollable Data Sources

The AUA agrees with the proposal to expand data sources used for the automatic extreme and uncontrollable policy to because it ensures impacted clinicians are provided reporting relief and are not penalized for suffering extreme circumstances outside of their control.

10. Removing the Public Reporting Delay for Improvement Activities and Promoting Interoperability Measures

The AUA supports the proposal to remove the one-year delay in public reporting for newly introduced improvement activities and Promoting Interoperability measures in an MVP because it promotes timely transparency and consistency in public reporting across the Quality Payment Program.

RFI: MVP Scoring Methodology

The AUA appreciates CMS’s interest in ensuring that MIPS Value Pathway (MVP) participants are evaluated fairly, both within individual MVPs and across different MVPs. We recognize the challenge CMS is attempting to address through this RFI: clinicians participating in different MVPs may have different measure options, benchmarks, case minimums, and scoring potential. However, the scoring approaches discussed in the RFI, including normalization at the final-score or performance-category level and the potential use of standard-deviation-based methodologies—would add substantial complexity to an already complicated program. Such methodologies could make it more difficult for clinicians to understand how their scores are calculated, predict their potential payment adjustments, and identify specific actions they can take to improve performance.

The AUA therefore recommends that CMS make no changes to the MVP scoring methodology before full MVP implementation. CMS itself acknowledges that participation remains nascent and that additional data are necessary to evaluate potential scoring concerns. CMS should first implement MVPs, collect sufficient experience and performance data across specialties and practice types, and determine whether a material scoring problem exists before developing another layer of adjustments. Any scoring changes at this time would require clinicians and reporting organizations to prepare for a new methodology while they are still adapting to MVP reporting.

Finally, Congress is considering legislative action to modify the QPP with a more streamlined, clinician-led approach to quality measurement. The AUA supports this direction. Given the possibility of significant statutory reform, CMS should avoid implementing a new and complex MVP scoring approach. At a minimum, CMS should defer scoring changes until full MVP implementation and sufficient data are available.

RFI: FHIR Digital Quality Measurement in the Quality Payment Program and Other CMS Quality Programs

The AUA supports CMS’s goal of advancing more standardized, interoperable, and automated quality measurement through the use of Fast Healthcare Interoperability Resources (FHIR). AUA strongly urges CMS to (1) account for current feasibility and implementation challenges before establishing any firm timeline, and (2) work closely with specialty societies and QCDRs to develop a practical and sustainable path forward.

AUA encourages CMS to support a transition that would reduce duplicative reporting, improve the timeliness of clinical data, and allow information collected during routine care to support quality improvement, registry reporting,  and  value-based  payment. However,  before  any  change becomes mandatory, CMS should demonstrate that it has been successfully tested across multiple electronic health records, practice settings, and reporting intermediaries; that the necessary data are consistently available and complete; and that results are comparable to those produced through existing reporting methods.

The AUA also urges CMS to involve specialty societies and QCDRs, such as the AQUA Registry, throughout measure development, testing, and implementation. Many clinically meaningful urology measures depend on specialty-specific information—such as PSA levels, Gleason Grade Groups, symptom scores, pathology findings, and stone characteristics—that may not be consistently available through standardized sources. This is a common issue for specialties and subspecialties. It is imperative for CMS to have the benefit of input from the specialty community about these important nuances limiting the feasibility of FHIR implementation in the short term. CMS should provide sufficient transition time, technical assistance, and appropriate flexibilities for small and independent practices, and should recognize registry-based reporting as an important pathway for supporting FHIR implementation. Registries have the potential to support the conversion of non-FHIR EHR data into FHIR standards, alleviating the burden for practices, especially those smaller, specialty EHRs that may not be able to meet updated CEHRT requirements easily.

Given the feasibility concerns described above, the AUA does not support the implementation timelines outlined by CMS. The AUA urges CMS to defer setting a mandatory timeline until sufficient testing and real-world experience demonstrate that the necessary data, technology, and workflows are consistently available and can support accurate reporting without creating additional burden for clinicians or impossible or unsustainable burden for measure developers.

Thank you for your consideration of our comments. If you have any questions or would like additional information, please contact Irfan Khan, AUA’s lead on payment policy and reimbursement strategy, at ikhan@auanet.org.

Sincerely,

Mark T. Edney, MD, MBA
Chair, AUA Public Policy Council

Anurag Das, MD
Chair, AUA Physician Payment & Reimbursement Committee

^{1. Medicare Physician Updates Compared to Inflation in Practice Costs (2001-2026). https://www.ama-assn.org/system/files/2026-medicare-updates-inflation-chart.pdf?utm_source=chatgpt.com Accessed Sept. 8, 2026.}

^{2. Federal Register ,Vol. 91, No. 135, pg. 43908}

^{3. Internal AQUA Registry data, available upon request.}

^{4. Internal AQUA Registry data, available upon request.}

^{5. Holzbeierlein JM, Chang SS, James AC, McKiernan JM, Schuckman AK, et al. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. American Urological Association; 2016. Amended 2020, 2024. Accessed August 21, 2026.}

^{6. https://auanews.net/issues/articles/2025/march-2025/centers-for-medicare-and-medicaid-services-approves-its-first-mips-value-pathway-(mvp)-for-urology?utm_source=chatgpt.com}