On November 4, the Centers for Medicare & Medicaid Services (CMS) released the CY 2027 Medicare Physician Fee Schedule (MPFS) final rule and fact sheet. The following is a high-level summary of the policies that will affect AUA members. AUA staff will review the final rule and provide a detailed summary.

Conversion Factor

As mandated by statute, there are two separate conversion factors: one for physicians and qualified healthcare providers participating in qualifying advanced APMs, and the other for those not participating in qualifying APMs: 

• Qualifying APM Conversion Factor: $32.95, a decrease of 1.83% from the current conversion factor.
• Non-qualifying APM Conversion Factor: $32.63, a decrease of 2.31% from the current conversion factor. 

The decreases result from the expiration of the one-year 2.5% conversion factor increase Congress provided for CY 2026.

Impact on the Specialty of Urology

CMS estimates the policies in the rule will have a net impact of -1% in total Medicare charges for urology. The negative impact is the result of finalized policies and the expiration of the +2.5% payment adjustment implemented in 2026. Some of the policies that affect overall Medicare payments to urology include the changes in payment policy for same-day E/M visits coupled with a surgical procedure, phasing out certain historical practice expense specialty data, and the deletion of code G2211 which will be replaced by a modifier to capture the work of complex patient care associated with an E/M visit. The final policies continue to exert downward pressure on reimbursement for physician services, even as operating costs continue to rise.

Note that impact of final policies on group practices and individual physicians varies based on practice type, payer type, mix of patients and the types of services provided to those patients.

CMS Finalized Nearly All RUC Recommendations for New and Revised CPT Codes Used to Report Urology Services

The AUA continues to serve our members by participating in the AMA RUC process and advocating for relative value units (RVUs) that accurately reflect the work of urologists. By participating in the RUC survey process, the AUA advocates for work and practice expense values for new and revised CPT codes. CMS accepted the AMA RUC recommended values for all the services recently surveyed by the AUA except for one code (55716) included in the revised prostate biopsy code family. The AUA submitted comments opposing CMS’s proposed work RVU for new CPT code 55716. However, CMS did not agree with the AUA’s rationale and finalized a work RVU of 0.68 instead of 0.80 as supported by the AUA and the AMA RUC.

Appendix A lists new and resurveyed codes with the recommended RUC work RVUs and the CMS final work RVUs for services performed by urologists.

Changes to Payments for Services Associated with Modifier -25

CMS modified its proposal and finalized policy to reduce payment when a separately identifiable office/outpatient evaluation and management (E/M) visit (indicated by modifier -25) is furnished by the same physician (or a physician of the same specialty in the same group practice) on the same day as a procedure with a 0-day global period. Originally, this proposal would have applied to 0-, 10- and 90-day global period procedures. However, CMS received comments opposing the policy including those submitted by the AUA. As a result, the agency made two concessions; 1) applying the policy only to 0-day globals, and 2) reducing the payment cut from 50% to 20%. Beginning January 1, 2027, Medicare will pay 100% of the total charges for the most expensive service (either the surgical procedure or the E/M visit) and 80% of total charges for other services furnished on the same day.

Changes to Additional Payment for Complex Patient Care – HCPCS Code G2211

Despite comments to maintain G2211, the agency will delete code G2211 (Visit complexity inherent to evaluation and management associated with medical care services) and replace it with a modifier.[1] The new modifier, B1, will have the exact same descriptor as G2211, and should be reported and billed in the same way as the G-code. The modifier, when appended to an appropriate E/M code, will increase payment by 16% of the value of the billed E/M service. The AUA submitted comments to maintain G2211 and its associated flat payment rate of $17.00 to preserve the associated work RVU of the code.

Remote Monitoring Services: Changes to Billing Requirements

Citing the need for appropriate use and billing of remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services, CMS finalized policy that requires practitioners who provide RTM and RPM services to first conduct a separately reportable initiating visit prior to starting RTM and RPM.[2] The initiating visit may be conducted either in-person or via telehealth and the use of RTM and RPM must be discussed with the patient. CMS also finalized policy that RTM services, like RPM services, can only be provided to established patients.

Additionally, citing a recent Office of Inspector General (OIG) report which indicated a need for additional oversight for remote monitoring services, CMS finalized that Medicare payment for RTM and RPM services will only be made when the services are provided by clinical staff employed by the physician or practice. However, due to overwhelming opposition, CMS is delaying the policy for two years to give practices and organizations time to train in-house staff to perform these services, or to hire additional staff. The policy as finalized requires that to count the time spent by clinical staff who provide RTM or RPM services, the clinical staff cannot be employed by a third-party contractor, the clinical staff must be a “direct employee of the practitioner or practitioner’s practice.” CMS clarifies that the clinical staff do not have to be physically located within the practice and the beneficiary does not need to be on-site. CMS believes that third party outsourced RTM and RPM services leads to fragmented care particularly given the third party has little to no connection to the patient, nor is there appropriate oversight and supervision of the provision of the services.

CMS Does Nothing with Comments Submitted Regarding AMA’s Current Procedural Terminology (CPT) Process

CMS sought comment on the federal government’s reliance on the use of CPT codes in its programs. Once again, the agency called out the “obvious conflict of interest of providing information on the time and resource requirements to conduct physician services when this information may influence their own payment.” CMS did receive some comments on the licensing process for using CPT codes, but very few commenters supported eliminating royalties charged by the AMA.

The agency received substantially more feedback on improvements to the RUC process that it did on improving the CPT process. In response to this public feedback, CMS is considering several potential approaches to reforming the RUC process but did not specifically state those changes in the final rule. Per CMS these approaches could address commenters’ recommendations to enhance transparency, improve the data used to inform payment recommendations, revise the RUC committee composition, increase CMS’s independence in making valuation determinations, and evaluate the retirement of low-value services.

Appendix A: RUC Recommended and CMS Finalized Work RVUs for CY 2027

^{[1] HCPCS code G2211 full description: Visit complexity inherent to new or established office/outpatient or home or residence evaluation and management service, associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.}

^{[2] CPT Codes 98975, 98976, 98977, 98978, 98980, 98981, 98984, 98985, 98986, 98979, 99091, 99453, 99454, 99457, 99458, 99473, 99474, 99445, and 99470 are used to report RTM and RPM services.}