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UCR 311: 2027 Medicare Final Rule Update — Conversion Factor Cut, Modifier 25 Reduction, and What It Means for Urology
•Episode 311
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32:06
November 10, 2026
In this episode, Mark Painter gives a summary of the 2027 Medicare Physician Fee Schedule final rule. Mark and Scott tell you how the rule changes payment for urology.
Conversion factor. The conversion factor for most urologists decreases 2.31% to $32.63. The cause is the end of the 2.5% increase from Congress, which was for one year only. Changes to work RVUs and practice expense decrease urology payment by about 2% more.
Modifier 25. Medicare will decrease payment when you bill an office E/M (99202–99215) with modifier 25 and a zero-day global procedure on the same day. The line with the highest payment stays at 100%. The payment for the next line decreases by 20%. This rule does not apply to 10-day and 90-day global procedures.
Practice expense and code changes.
The new practice expense method starts in 2027. Medicare applies the change during two years.
The practice expense decrease for cystoscopy continues for a third year.
The practice expense for urodynamics increases a small quantity.
Payments change for the revised prostate biopsy codes.
The payment for 51715 now includes the cost of the bulking agent. As a result, practices do not bill the L code separately in the office.
Other topics in this episode.
RPM and RTM requirements
Urology MVP changes and the end of traditional MIPS by 2031
Decreases in the clinical lab fee schedule
New Category III codes and PLA codes
Modifiers B1 and B2, which replace G2211
Software as a medical service
Electronic prior authorization
The hospital outpatient and ASC rule, with the 2.3% increase and the changes to 340B drug prices
What to do now. Congress can restore the conversion factor increase during the lame duck session. Mark recommends that practices speak with their EHR vendors now. Mark also recommends that practices improve their templates for documentation and orders.
To learn more, come to the Urology Advanced Coding and Reimbursement Seminar in December, or in January in New Orleans.
Join the Urology Pharma and Tech Pioneer Group Empowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner. https://www.prsnetwork.com/joinuptp
On this episode, the Final Rule 2027 Update. Stay tuned.
SPEAKER_01
Today's episode is brought to you by ModMed. Do your EHR and PM adapt to your style of practice? The ModMed, EHR, and PM do, with benefits like remembering preferences and automatically suggesting documentation and billing codes. Urologist voted ModMed the number one urology-specific EHR and PM solution available. Built by urologists with input from yours truly. Stop wasting 60 minutes and 200 for each of your open or no show slots. Go to modmed.com slash PRS Network, set up an appointment with the team at ModMed Urology, and shift your urology practice into high gear. Imagine a solution on a tablet or the web that works seamlessly with revenue cycle management, analytics, telehealth, payment processing, patient engagement tools, and much more. ModMed is transforming healthcare by placing doctors and patients at the center of care.
SPEAKER_00
Welcome to episode 311 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, my co-host Mark Painter, Dr. Ray Painter. And on this episode, Mark is going to give us the final rule update for 2027. So we'll let him present this, and then Ray and I may have a couple questions, but it might be just uh uh information dump from Mark. There's a lot of information to cover, so we want to do it as quickly as possible and succinctly. All right.
SPEAKER_01
It's all yours, Mark. All right, so the final rule dropped last week, Wednesday, so it's not even a week old. So we were at the Lugpa conference and got a few updates on some of the interpretation on this, which was interesting. But I'll just run through first the highlights of the final rule, or probably the lowlights, depending on how you're doing this. So make sure you're sitting down. The rule the the the news is normal, as we see it year to year these days. So, first up, we'll go ahead and give you the conversion factor update. The looks, the non-qualifying APM conversion factor, which applies to the majority of urologists, is gonna drop at this point in time to $32.63. That's a 2.31% drop from its current level of $33.40 and change. So we are gonna see that conversion factor drop. The main reason that we saw that drop was because that when instead of the raise was that that 2.5% bump that was passed at the last minute by Congress has expired. It was a one-year bump. We're hopeful that happens again. Obviously, there's gonna be a bit of a shakeup of in Washington. We've got this lame duck session that would be, in some people's opinion, the ultra-lame duck session. I don't know exactly what that name is for that group when the total change in power is coming through as far as in the Senate and the House. But they do have a number of things that have to be addressed during the lame duck session, including the defense budget and the overall budget. The government's scheduled to shut down on December 11th. So there's a good possibility there will be some tag-ons in there. The two and a half percent might get restored. There is some discussion about doing that. But it could be that they can't get anything done, and we're back into next year hoping that the next Congress does some does something. So we'll keep an eye on that, but that's where we're starting out from. Work RVUs and practice expense changes. So these are kind of behind the scenes, are gonna net about another negative 2% drop for the urologist. So we're definitely looking at some drops and obviously bigger to some than others, based on how you practice and where those code hits on the RBUs are. Medicare did finalize the rule that they are going to start reducing procedure codes or the EM code next year when the EM code is billed with modifier 25. So the rule is that it's only going to apply to a modifier 25 on the same day as a zero-day global procedure. So this is not going to affect your 10 and your 90-day global procedures. So we won't see reductions on EM on the same day with 10 and 90 procedures. They are going to limit the reduction to only the office or other outpatient codes. So 99202 through 99215. Now, the way that they're setting this up is that the highest paid line will stay at 100%. So if you're doing a cath change and an EM code, the catheter code will be reduced by 20%, not your EM code. But if you're doing performing a SISTO and an EM on the same day, the SISTO would be paid at 100% and the EM code would drop by 20%. So that's the plan at this point in time as we see it. I mean, there were obviously some wording issues and examples, not obviously, but stuff that we identified in the final rule that were interesting that we'll keep an eye on. The verbiage in the final rule was that it was 20%, and it would be applied to all codes on the same day. But that's not what we actually are hearing in the back end. They that was a misstatement that in fact it would be 20% for the EM code or the next highest valued service code. And then everything else would fall under the standard multiple procedure reduction. So this is layered on top of that. One of the reasons, so I'm going to jump now to the next thing. The one of the reasons we're going to see a little bit of a dip in the practice expense code for urology is that Medicare it did finalize their rule to change the way they're going to develop the practice expense. They removed the current benchmark for practice compensation, and they are going to replace it with a new formula. They are going to phase this change in over two years, and they put in a stabilization cap that they said would protect everybody from wild swings. We have yet to really see how that's going to be applied or whether or not it impacts urology. Our cystoscopy cut, which has been happening since 2025, continues. This is the third year of that phase in. So we're going to see a reduction of about 25% somewhere in that realm of the practice expense value for the cystoscopy. We're going to see a little bit of a bump in the practice expense value assigned to Eurodynamics. Medicare had proposed not to touch this because they had a suggestion that they had misvalued those catheters that were part of Eurodynamics, but arguments were put forth and CMS accepted those arguments. And those updates, all of which were actually not all, most of them were positive, are going to be a part of the tax expense value for all of your Eurodynamics codes. So those are going to go up a little bit. We do have our prostate biopsy code changes. Now we've talked about the code changes in the past when we did the CPT code update. The reimbursement issues across the board, really fairly minimal for each one of the codes. The 55707, 08, 09 are all going to drop by about 3% in the facility, and they're going to go up a little bit in the non-facility side, like a little around $10 for each one of those codes. The 55710 is going to jump about 13 in the office, minus 4 in the facility setting. And then the 55711 was which is your first targeted lesion only code. Remember that changed on approach. So they no longer care whether it was transrectal or transparineal. It's all been collapsed into the 55711. That dropped about $17, but that is actually up when you consider the code that was removed for the trans rectal on all this stuff. So we've got that. Each additional lesion code is going to drop about $17. Again, a very small drop of $3 for the inboard, a rise of $32 in the non-facility setting, and then a significant bump for the each additional lesion in the inboard in the office at $438, and a $31 bump in the facility setting to the physician. So we'll see all of those come into play. And I'm not going to really comment today on the outpatient rule with a few exceptions, but we're not going to give you the final numbers on the outpatient rule as to what the ASC is getting paid for prostate biopsies. We'll do that in a future episode. Bulking agents, 51715. They finalized the rule that they are going to include the cost of bulkamid into the practice expense value, which is going to result in a significant bump on 51715 up to $1,310.02. This also means the L code will no longer be billed separately for in-office bulking agents. So that's a net positive for urology. Then we saw them finalize the rules around RPM and RTM or remote physiologic monitoring and your remote therapeutic monitoring. They did adopt their proposed rule that it has to be an established patient, that the physician needs, or the QHP, it could be an APP, must be involved in an initiating visit, and they are going to adjust the payment slightly for those codes. What they did not accept is that the person furnishing RTM or RPM has to be an employee of the practice. So they had originally proposed that they were going to force all RTM and RPM codes to be provided by employees of the practice. Again, they decided not to carry that forward. They're going to continue to study that. We do have some changes to the urology MVP. They added a few codes and removed a few of the MIPS measures. Most of those were fairly small changes, but they did tell us in this final rule that MIPS will be phased out by the year 2031, and the QPP program will require MVPs as of 2031. So it's time to start making that switch now. Start talking to your EHR vendors and building your protocols and the QPP program towards that MPP or the most valuable pathway. Labs. The clinical lab fee schedule is going to see some major changes, mostly in the negative direction, because they there was a second law that protected the current fee schedule. That law is expiring, and CMS is going to phase in those changes over fairly quickly, but over the next two years starting in 2027. Had a few other code changes that will affect some, but not all of you. Couple of changes in the PCR codes that are out there that will cause us to take a look at how PCR is billed. And then a couple of other predictive tests that are have been revised, as well as a new code for a nucleic acid detection of candidia of a copolakites plus trichomonis vaginalis, so a little more of a code really targeted towards female urology. And then we now have a skin cell suspension autograph code series in the 15006 to 15009. So those are things that might affect your practice. We've got some new category three codes. Basically, Medicare or CM or excuse me, AMA announced that they're changing their timetable and are now going to release category three codes on October. They're three times a year, and October 1 was the first time they've released it. So we've got a few new codes out there. We can I'll run through them actually very quickly. We've got an absorbal urologic scaffold, the 1042T. We've got three new codes for algorithmic oncology treatments, two for the bladder, one for the prostate, and the 1063T, 1064T, and 1107T. And then we've got a few new codes that came in in October one. One for a focused non-shockwave propulsion of stones, the 1054T, and then four new codes for CO2 cryotherapy in a gaseous bladder for treatment of minor, small, medium, and large lesions. We've got some new PLA codes for cancer for prostate GU cancer and kidney. The PLA codes are codes that are targeted to proprietary labs. So you'll probably start seeing a little more activity on labs wanting you to perform those particular tests. And generally, the reimbursement changes overall are going to be in the 5-6% range at a maximum negative. Most of them fall into that range of 0 to 5%, with only a couple of them going positive, including some Eurodynamics technical components and the 51715. The hospital and ASC, again, I said told you I'd give you a high level here. They got a 0.23, uh 2.3% increase across the board, but they also have some 340B pricing changes in the hospital setting that are going to change the way hospitals deal with drugs that are provided as part of a treatment that were paid under ASP or excuse me, under 340B pricing with ASP plus six. In the HOPD, that's going to be AO ASP minus 28%. That one I would expect will get litigated, so we'll see what happens there. And then with the in the ASC, the 340B offset is up to 2%, grows to 2%. So a couple of things there that are going to indirectly affect how those entities work. We didn't see or we saw what we expected a slight bump in the C9761 and the C8014, but a lot of our other changes were not as big, although we did see a few codes get moved into device intensive status. So you'll want to take a look at some of those category three codes and how they pay in the ASC. The inpatient only list is continuing to be phased out, and the ASC covered list is continuing to grow. So we'll see that continue over the next couple of years at least. From the telehealth side of the equation, I'm going to go through this very quickly. Mostly all of telehealth stayed the same. We've got one issue that we need to bring up, and this is, I'm going to bring it up in a minute, but we did have a couple of new shared medical appointments. The way they finalize these, it's going to be really focused on a lifestyle-based treatment for a chronic disease state. So there may be a couple of applications for this in urology, such as anything that's diet or weight-based, maybe some behavioral stuff with OAB, but we're going to have to see how they flesh that out a little bit more. And then the G2211 is going to change. G2211 will be deleted, and we are now going to report the same chronic disease state management with modifiers. Modifier B1 for most of you is the correct code, and it is supposed to pay 16% more or 16%. Yeah, the it'll bump your ENM code by about 16%. And then B2, if you're in an ACO model, that would bump by 32%. But the rules on modifier 25 continue, meaning we can't use modifier 25 and the B1 or B2 modifier. And you don't use both. Most of you will use B1 for your modifier. And then the last thing that I wanted to really look at as far as some of the changes in Medicare is they did finalize that they are going to start phasing in software as a medical service. They're reclassifying some codes and looking at how to value these services differently, really to accommodate algorithmic diagnostic tools as well as any algorithmic treatment tools. So the big acknowledgement, if you will, which is a step in the right in the step in the direction of handling software as a medical service differently than they do in person or provided by a physician visits, is going to kick off in 2027. We'll probably be talking about this quite a bit, but they've named 36 HICPIC codes in the outpatient rule and another 10 really in the Medicare fee schedule that are specific and urology related that will fall into that software as a medical service category. And then the last thing I wanted to mention overall was e-prescribe or e-prior authorizations. This really isn't part of the Medicare final rule, with the exception of the fact that as part of your MIPS program for 2027, you are going to have to process at least one electronic prior authorization. The bigger change is going to be how the private payers who have signed on to this initiative. With CMS and what they're gonna do. The overall goal of electronic prior authorizations is to get rid of fax and portal submissions and to make everything API, meaning automatic transactions that essentially allow the EHR to give the prior auth information for particular codes. This is going to require a lot of work on a lot of different people, including your EHR vendor. So what I'm going to recommend at this point in time, because this is coming in to me ahead of when it's ready, is number one, you want to talk to your EHR and your practice management system vendor about what they're doing and how much they're participating with the health, excuse me, the health tech ecosystem or CMS0057. And then I'm also going to encourage you, and I think this is something that all of you should do anyway, is improve your templates to make sure, again, and actually this isn't a new thing, but I'm certainly going to reiterate it here. Make sure that your documentation and your ordering protocols are truly reflective of the requirements for billing and coding. So take a look at where your templates are, your surgical schedule orders, those types of things, and really make sure that you're getting all of the information required to make sure that service will be covered Because the prior authorization is going to depend on it. And I'll stop there.
SPEAKER_00
All right. So let's hit some highlights really quickly. Just some your feeling when you look at this. What's your overall analysis of just good for urology, bad for urology, indifferent for urology?
SPEAKER_01
Well, I would say it's not good for urology. It's not horribly bad for urology. It is yet another step in the road we've been on for the last several years. At least we didn't get a 2.5% across the board adjustment to the work RBUs. I mean, I can pull out a few positives here and there. It wasn't 50%, it's only 20% for the ENM25 reduction. It's not to all ENM codes and not to all globals, just to zero-day globals. So there's there's some small wins that are out there. And certainly there's some losses. So I'm definitely not putting in the positive category, but I'm not putting in the double puke factor either.
SPEAKER_00
All right. Could have been better. Yeah. And much better.
SPEAKER_01
Every year.
SPEAKER_00
But it is better than what was proposed.
SPEAKER_01
Yes.
SPEAKER_00
Okay. All right. And then what are you looking for in this lame dog session? I mean, what are the one things, if you were to really say what can they fix or what would help urology in a legislative action? What are you hoping for, I guess?
SPEAKER_01
The conversion factor bump. I think that's the one piece that we could potentially see addressed in this lame duck session. So when we get into talking about next year and the change in control and what's going on there, there's a broader agenda that we're going to have to keep an eye on. Some plus, some minus. But when we look at the lame duck session, I think all eyes are going to be on the 2.5% bump to the conversion factor. And maybe CMS comes in and makes them delay the 25 modifier for a year or pushes off 340B pricing. I mean, there's always that wild card issue that could happen, but it's I know in the end that 2.5%'s the one I'm hoping for, and the one I'm thinking they might actually act on based on the fact that it's the Republicans that are on their way out, and their long-term fixes probably that appetite is probably not there.
SPEAKER_00
All right, final question. What do you think is going to take the most time from your RCM group to implement or to prepare for of the changes that are coming down the pike?
SPEAKER_01
I I don't think there's anything in this final rule that is going to significantly increase the activity that's already in place. The fact that they're gonna continue what they're doing with the lookbacks, the rack audits, the so our hot topics have not been resolved by this, bottom line. We just got a few more layers on the payment policy side of this. I think that's probably the biggest. And some of the discussions around how poorly the Wiser program is going, Those things might be something that could crop up as far as delays or changes that are out there. But yeah, I think bottom line is we're seeing the actions we're seeing.
SPEAKER_00
All right. Okay, well, let's wrap this episode up here. We 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 forward slash PRS network for specials for our listening audience. All right. I know we kind of did a wrap-up summary. Is there anything else you want to add to this discussion today?
SPEAKER_01
So I guess the only thing I would add in all this stuff is a lot of this is driven, and at least the conversion factor side of this is driven by the legislation that's already in place. So we need the legislator to get off its collective behind and actually act to fix this long term. So that's one thing I'll add in here. The second piece that I'll just throw into this mix is even with budget, even with changes to the fee schedules, I mean, the budget side of the equation is still real and still is out there. We spend a lot of money on healthcare. There's going to be a lot of focus on what we can do to control the spend in healthcare. And once again, physicians as a group of smaller businesses is likely going to take some of the heat in all of this. And if we can divert some of this over into the hospital side and into the pharmaceutical side and the insurance company side to help share the burden of all of this, I think that's where we need to go next. It's no matter how you look at it, people are the overall costs of healthcare are going to be a target for a while.
SPEAKER_00
And it's hard to compete against those others that have all that money in their packs and their all the political money going in and the doctors being a little less organized and having a little l having a lot less money. That's that it's hard to win that battle. Do the best, yeah.
SPEAKER_01
But it absolutely needs to be fought.
SPEAKER_00
Yes, it does.
SPEAKER_01
Yeah.
SPEAKER_00
All right. Well, that's all we have for today's episode. If you want to talk about this more and you want to hear more about all these rules and really digest them in a much deeper setting, you can join us at the Urology Advanced Coding and Reimbursement Seminar, which we're actually looking at adapting the name of that to include a little bit more, because we do cover kind of the whole revenue picture of the urology practice. So whether you're in academics or in a hospital setting, working for RVUs, just understanding kind of how it all fits together and the rules associated with that. So we will talk about all these new changes at the Urology Advanced Coding Reimbursement Seminar in December and in January in New Orleans. And you can go to PRSnetwork.com to find out more information about those seminars and pricing and registration. All right. That's all we have for today. Thank you all for listening. Take a time, Mark.
SPEAKER_01
Happy coding and reimbursement.
SPEAKER_00
Thank you for listening to the Urology Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to Fellow Painter for the music today. You can find his music on Spotify under his record label YouTube.
