On this episode, initial reaction to the proposed 2027 rules for Medicare. Stay tuned.

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Welcome to episode 296 of the Erology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host, Mark Painter. And wow, there's a lot to unpack there. In the proposed rule, Mark, do you want to get started? Let us know what you think.

All right. So we'll start with the conversion factor. As expected, the conversion factor in the proposed rule is projected to decrease. We knew that this or we suspected this would happen because our 2.5% temporary one-year bump was an act of Congress. So Congress has not yet addressed this new rule, nor the fee schedule at all. So we're looking at the standard rigmarole related to budget neutrality. So the average urologist or the majority of urologists will see a decrease in the conversion factor of about 1.68% down to 3284. If you're in a qualifying APM, the reduction is slightly less at 1.919% down to 3316. So that's our jumping off point as we talk about everything now a little bit deeper for some of the reasons and some of the interesting changes that Medicare is proposing. Now remember, this is all proposed rules. So, and as we know, you know, proposed rules tend to become final, but we do have the opportunity to comment, and we have seen some changes on different things. And CMS was a little bit lighter in a lot of the things that they addressed this year with proposing and increasing comments relative to everything that was put out there. So we'll have to see how everything shakes out. And the other thing I think we've got to consider, at least with some of these, that they actually put in some caveats, and I'll try and highlight those as we get to them. So from an overall RVU standpoint, Medicare is projecting a negative 1% decrease in urology based on work RVU impact and a practice expense RVU impact of minus one for a combined impact of minus two. The bigger hit this year is in the non-facility side. You may recall that last year we saw the across the board adjustment to the practice expense in the facility side. Although Medicare continues to think that there is some overpayment in the overlap relative to the facility and the physician, because of the 50% number of physicians employed by hospitals, they didn't propose anything new this year that gives us any of those drastic drops. The other thing that Medicare reiterated is that the adjustment, that 2.5% adjustment to the work RVU efficiency adjustment that went into play last year is a three-year circulating issue and ultimately will not impact 2027. But there are some different things that are hitting across the board that ultimately are going to be impacts to the revenue stream that aren't as visible on the RVU side if you're on an RVU contract and your contract doesn't actually take into adjustments. But there's some big proposals in here that are in some ways understating the impact across the board for urology. So this is something that overall we're going to have to unpack a little bit more, and we'll certainly do that as we go forward, and we'll adjust, we'll give you kind of little previews as we go through as best we can. One of the biggest things that was proposed for next year is applying the multiple service payment reduction to ENM codes with modifier 25. What that means, in the way that they've reproposed this, is that if an EM with modifier 25, which currently is paid at 100%, is reported on the same day as another procedure, so the modifier 25 was required, then the highest valued procedure or the highest valued service that was provided on that day would be paid at 100%. So that could be the EM code. Every other procedure billed on the same day that is subject to multiple payment reductions, now including the ENM code, would be reduced 50%. So a typical visit where you saw a patient, let's say, for surveillance on bladder cancer, we saw recurrence, sat down with the patient, the CP, the CISTO would be billed, the ENM with modifier 25 would be billed. The CISTO being the higher valued code would be paid at 100%, and the ENM as the lower valued code would get paid at 50%. Conversely, if we took a look at, say, maybe an injection procedure visit or a catheter change visit or even a PTNS visit, those which are all lower paying, then the EM code would pay 100%, and your injection code or your PTNS code would be reduced by 50%. So that's a big one. That is something that I think deserves comment across the board, and certainly is an impact that really isn't taken into account in the calculations we see from the Medicare side. There were some overall projections that Medicare hinted at relative to that reduction in payment that allowed them to adjust the conversion factor and maybe a few of the RVUs across the board, but it doesn't appear that they took that into account in the general impact in that 2%. So they did not list urology as one of the higher impacted specialty for this current proposal, but it is definitely going to be an impact to urologists and probably not all of them equally. Now, I'm my in my estimation, there's a number of issues wrong with this. Number one, the 50% reduction that is applied to multiple procedures is really a reduction in work and practice expense. But because most of them are provided in a or most multiple procedures, or many multiple procedures are provided in a facility setting, the majority of the impact is work RVU. When we really take a look at the definition of modifier 25 and really the work effort that is paid for under modifier 25, I don't really see that there's any work RVU overlap. And I don't think that should be calculated at all for a reduction. Now, I can see Medicare's general argument that administratively you only have to send out one bill for the day, you only have one check-in. So maybe there's some direct labor costs that and indirect labor costs that might be somewhat reduced because of the same-day service. But that 50% is far too high. So I expect that the AMA and most of your surgical specialties will weigh in against this, but I think this is something we should all weigh in against, and at the very least, lobby for a different reduction. Now, Medicare, I think, acknowledged this a little bit in publishing the in the published discussion about this proposal, saying that they might take into account some of this relate and use maybe a different M MPPR or the reduction number. And instead of going with 50, maybe they mentioned 25% reduction. So it is going to be something that they look at. We need to make the arguments and make them in a way that makes sense to Medicare, and hopefully we'll at least stop this. But I the other thing I would say that this opens the door on is what are commercial payers going to do? And so that's going to be one that we're going to have to watch. We've already seen many commercial payers try and implement a policy like this in Michigan, Massachusetts. I believe they've already implemented it. They've fought it off a couple of times in Michigan, but this is going to open that door up now that CMS has even proposed it.

So we're going to see it across the board. So quick question for you.

Or quick comment. When you were reviewing this, you noted that this was mentioned in a very small part of the rule. Out of the thousand-page rule, it was just a a paragraph or so. So I just find that interesting that it's just kind of slipped in there in a way.

It is slipped in there. And it was and it didn't really come up as a big verbal thing. Now they did acknowledge it as something that folks would probably push back against. And I think there's some other impacts in this that are a little more subtle. You know, Medicare always already has a work RVU adjustment programmed in to procedures that are often, or excuse me, all procedures because of the potential of a ENM on the same day, which ultimately, if they implement any reduction, they need to go back and fix that in other in the RVU, the work RVUs for many of the procedures. So there's it the this impact is broader than it looks. And you're right, Scott, they really didn't give it, you know, verbally, the space impact that it really is going to be in the overall rule.

And the same thing seems like with the uh the next topic you're gonna bring up.

Yeah, so G2211 is you know one of the codes we've been talking a lot about since it came into Medicare a few years ago. This rule proposes eliminating G2211 and instead replacing it with a modifier, uh yet to be introduced modifier in official Hic Pix language, but a modifier. They are raising the rate, and they are looking at it as a maybe a better reflection of the G2211 relative to the work RVU assigned to the EM code. So the payment now is going to be a percentage of the total RVUs associated with EM code. So it now actually changes how much you're paid based on which ENM code is being charged for that particular visit. Their argument, of course, is that a more complex ENM visit has an associated complexity of that long-term care component. So that's a good thing. So that could be a big impact for urology in the positive direction, and certainly is something that the general concept seems supportable, but it will change a number of different things on how we handle this in the EHR. And ultimately, the other thing I think everyone's gonna need to consider is what does this do on an impact basis for your contracts? If you're paid on a contracted RVU production rate, how are your pay or your employers gonna add that work RVU adjustment in based on a modifier? And is that modifier, a demand to add that modifier adjustment in moving forward going to be something that opens the door to maybe look at the 50% reduction for multiple procedures or reductions based on a 78 modifier if they're not already doing that? It does help on the modifier 22 argument. So if you've got that in your contracts, that's something that they can programmatically handle. But if that's a new concept, that may be a bit of a Pandora's box as you look at the potential up and down on work RVUs across the board. But the volume associated with the potential of G2211 may in fact make that a difference. And then, of course, interestingly, the those practitioners are in an ACO, they're actually going to make that long-term care adjustment much higher. They're gonna actually double it at 32%. So if you're in an ACO, the G2211 replacement modifier is gonna be even more important. They're still gonna keep the modifier 25 restriction, but we still will not be able to use the modifier if modifier 25 is being applied to the ENM code. So it's not gonna save us at all relative to the reduction in payment that the modifier 25 is going to impact. Now, there's a few other changes that are underlying some of the RBU side, and a lot of this is technical, so I won't go into too much detail. But we did walk through some of the methodology that is currently used to develop the practice expense and the work RVUs. You heard a little bit of that commentary related to the impact on the work value for the same-day EMs, but there is a fairly detailed description of how Medicare comes up with the practice expense and the work values. And one of the practice expense basis bases in the calculation is an indirect cost of practice index, which is based on a study that was done back in 2015. So they're proposing to get rid of that and several steps in the overall calculation of the practice expense. But that one's one of the biggest ones. And because it is a big impact, they are going to phase that in over two years. So the any practice expense fee or unit that's in the system that's impacted by this new methodology significantly will only be adjusted halfway to its final in 2027 and then finished in 2028. So that's a phase in. And then they're gonna add in and a stabilizer, which is gonna try and make and uh make some of these adjustments less impactful as they move forward. So in the end, we're gonna see this impact a lot of different things, a lot of your services very differently, but that methodology change is one of those that's kind of behind the scenes, and you'll see that hit things differently. The other thing they really focused on quite a bit is our codes with the PC and TC breakdown, and that is going to impact the practice expense for some of your technical components. We are going to see that, and we've got a glimpse of that, and we'll do a more in-depth breakdown of the RVU impact at another date. But the preliminary look really looks like Eurodynamics is impacted by that indirect practice expense cost, and that changed significantly. So we'll see some drops in the Eurodynamics codes at reimbursement as we move into next year. The will just remind you of the impact of the supply pack for the CISTO visit for the in-office CISTO procedures. We are in year three for 2027 of the four-year phase in. So we're gonna see once again a bit of a drop in the systosopy family codes. We are gonna see another revision to the prostate biopsy codes. Again, we'll talk about the financial impacts of this at another visit or another podcast, but we are gonna end up with some changes in the CPT descriptors that are gonna impact both the documentation and the selection of these codes. I think the impact is gonna be relatively minimal for many of these changes because of some of the stated rules and AUA positions on non-lesion focused prostate biopsies. But the verbiage is changing for these codes to really focus less on whether or not fusion was used and more on whether or not fusion was used to target specific lesions, and at least from the regional biopsy standpoint, fusion won't be making as much a difference. But fusion will make a difference or somewhat of a difference relative to the lesion-based codes. And then there is gonna be some, there are some changes for the each additional lesion coding that we'll need to take into account. So we will give you some additional focused information on these codes at another episode, because we're gonna get a new code and some shifts in some of the existing codes. So we'll walk you through that in an session down the road dedicated to prostate biopsy, which bump in the value and the reimbursement assigned to 51715, which will now include the cost of the bulking agent, and specifically the bulking agent costs were tagged by Medicare to be $1,175. So that's going to be a big bump, about a 300% jump in the reimbursement for 51715. And the we're now gonna probably see. The associated L codes for the actual bulking agent phased out in this in this change. So that'll be something that'll be helpful next year for moving that particular service into the office setting for those of you who do that. A couple of other random, interesting things, and Scott, actually I'll ask any questions you or comments you want to make with what we've talked about so far.

So only question I have for you is when you're reading through all this and you're thinking about the urology practice, what what's your overall feel about the proposed rule? Are you looking at it as a bad thing, uh thing, or a good thing? How does it rate just as a barometer check overall?

Well, I gotta say the proposed 50% reduction in modifier 25 EM codes is a big negative, in my opinion. I don't think they factored that in correctly. I hope that's one of those areas where we can make an impact on this. I'm worried about the application in the private sector with that. So to me, that's a big strike against the overall proposed rule. Some of the other information that they have in here is kind of a, you know, if for lack of a better way to say it, expected uh issues as they relate to the update from one year to the next. You know, our proposed negative conversion factor, we always see that the proposal to the practice expense and the indirect costs, that's gonna be an interesting hit and the shift on how they're gonna address the technical components. Again, not what I would consider positive. So those all weigh on the negative side. And then from the other part of this, you know, I guess I would put it into another year, another set of increasing focuses that are going to cause us to maybe make some shifts in our projections. But that you know, there are some positives, and that happens every year. So I'd put it on averages slightly below regular year stuff, but you know, in general, my presentations that I give every year going forward, there aren't, you know, it ends up not being the most positive of all, except for maybe 2021 when we saw an 8% increase because of the EM code change. So it's not in the worst of all things. Like last year I would consider was horrible with the facility impact and the adjustments to the RBUs across the board. This is nowhere near the bad that delivered to us. So it's not the worst, it's not the best. It's about average.

All right. I think that's a good assessment, and I think you're right that and I know when we were preparing for this and discussing this, you already had an argument that we're going to submit for the modifier 25 reduction.

So all right. Let's keep going.

All right. So some of the other things that are out there, and let's actually start with telehealth. So telehealth is gonna remain the same in 2027 for the most part. We're not gonna see a big piece or a big change here. That was a statute direction from Congress. So CMS didn't have a lot of wiggle room there. They are gonna add a couple of interesting things that we'll have to explore a little bit more deeply. And one of them is the potential for group medical visits. This is something that is, you know, kind of caught my eye going through this. We'll do a little bit deeper dive on this, but there is a potential now to do group medical visits with patients who consent to be on a group medical call. These calls are typically, in Medicare's eyes, gonna last between an hour to two hours. They're typically going to have two to ten patients in them, but could be up to 25 in certain circumstances, but are going to be focused on patients with the same chronic medical condition. Patients are gonna have to agree to have their personal information discussed in these groups, but Medicare believes that the exchange of information among the patients will be a valuable addition to the clinical exchange. They're thinking that it may be more than one person from the physician office who's involved in these visits, the physician plus maybe some support staff to help with development of plans. It is going to require documentation in each individual patient's chart, and you are gonna be able to bill this code for each patient that attends. So there, you know, that one was is very interesting. We'll have to see if that one stays in the mix. And then pseudo-related to that, CMS is really taking a look at remote patient monitoring codes. They've kind of flagged the use of third-party groups to provide remote patient monitoring and remote therapeutic monitoring, and have proposed that will no longer be allowed under Medicare, and that anybody providing remote patient monitoring will be required to be employed by the physician practice, and that these services can only be provided and built under physicians with an established relationship with the patient. So I don't, you know, that's not a lot a code that a lot of folks use, but there are some codes in there that may be affected by that particular ruling. And then a couple of other things that are kind of more global in the comments that CMS makes, and some of them they make every year. One of them, global surgeries. They're gonna stop collecting data the way they have, which was focused on a few states requiring significant or larger practices to report the 99024. They floated the idea, but did not make it a proposal for 2027 that they were gonna require every practice to submit every follow-up visit with a 99024, even if we're not getting paid for those services. So that I didn't like to hear, but of course, we'll have to see if they bring this up. But as you know, Medicare's been focused on global procedures for a long time. And then a few of the other things that were interesting, there's some additional focus on clinical lab fee schedule. And now that there's been some protect, some legislative protections that have expired, Medicare's looking at making some reductions in the clinical lab fee schedule. That we'll have to dive into a little bit deeper. And then, of course, Medicare's annual mentioned that they really don't like the RUC. They really don't like CPT, and they're looking at maybe alternatives to both of those particular programs and the nomenclature of CPT as the base for Medicare. Now, they do mention that routinely every year. Obviously, this has been a mention or a target for the current administration. This is something that the current Secretary of Health and Human Services has very publicly stated that he's not a fan of CPT and would like to see an alternative system developed. And Medicare is encouraging people to come forward with that. They're also thinking about changes to payment reductions and frequently frequency limits. All of these are kind of loose-floated services that are out there. And then finally, we should mention the MIPS macro program. We did get some new measures in the MVP. And so we've got a few new measures proposed in the MVP program, the one for urinary and continence plan, the one for patient-centered surgical assessment risk, and then bone density. All of those are essentially moving from the single measures into MVPs, which of course are more group measures and might provide something more to look at.

All right.

Well, you certainly gave us a lot to think about and provided a good summary of what's going on with the proposed rule. Appreciate all that information. I think we're gonna go ahead and wind this episode up here. We want to make sure that you understand that we are gonna dive into these proposed rules and the values and the RVUs and all that in upcoming episodes. So we will continue to break down the what's coming down the pipeline. All right, but we also want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com or slash PRS Network or specials for our listening audience. Also, we want to thank Eurogen, manufacturers of gel mito and Zazduri for supporting this episode as well. You can go to gelmito.com or Zazduri.com for more information. Okay. Mark, any final thoughts? I know you gave kind of a summary, but uh you have anything more to add to this episode.

Well, it you know, with what we've got coming in our direction, I think it's more and more important for individuals to work through their societies, their organizations, and in conjunction with them, with comments on their own, and really well-worded commentary on some of these proposed rules that are not in favor of urology, as well as supporting some of those that are in favor of urology to move forward. It's time to get a little bit active, push back on Medicare. As we know, Medicare has a great deal of influence beyond just what happens in your Medicare day-to-day lives. Obviously, Medicare Advantage plans, but even beyond that, as far as what Medicare's influence is across the board. So we want to keep an eye on that. And again, we will be discussing this with others. This was our initial crack at digesting this ginormous document with all of these very detailed discussions and changes. So stay tuned as we dive through this deeper and pick it apart. And then, of course, again remind you that is it is in fact a proposed rule. So we'll have to see what happens in the final rule and where the comments lie. So and then I also apologize for the background sitting outside today. It's actually a pretty nice day here in Colorado in the shade. Not in the sun, it's a little hot, but we had to relocate for this one. So apologize for the background noise.

All right. One thing I will remind you that the urology advanced coding and reimbursement seminar registration is open. And we have a seminar coming up in December in Las Vegas and in January in New Orleans. And at those two seminars, we should have a lot more information on what's actually been adopted, and we'll have the final rule. So we'll be going over that in the seminar. So we encourage you all to join us for that and really prepare your practice for all the things coming down. I know there's a a lot of things that you have to deal with on a day-to-day basis in your practice. And, you know, planning for the future sometimes gets pushed back, but we want to help you make sure that you're prepared for 2027 and beyond. So that's attending the Urology Advanced Coding and Reimbursement Seminar. We can help you do that. Also, we want to let you know that the PRS Coding and Reimbursement Hub is being updated and more and more information is being added to it. You can check out the hub at PRSnetwork.com forward slash urology hub. And there you'll find information on various categories, how those categories are impacted by the coding and reimbursement, and what you need to pay attention to, as well as products for those particular categories. So specific products associated with treatment for a different specific urology category. All right. That's all we have for today. Thank you all for listening. Take a towel, Mark.

Happy billing, coding, and planning. Thank you for listening to the Eurogy Coding and Reimbursement Podcast, where we help Urologis and our staff. That's my information for time in 2015. Special thanks to Carl Painter for the music today.