Jonathan Rubenstein, MD

On August 3, the Centers for Medicare & Medicaid Services (CMS) finally released its proposed rule for the 2021 Medicare Physician Fee Schedule (PFS). The release date was later than previous years, as it is typically released the last week of June or the first week of July.

What do the proposed changes mean to your practice? In this article, we will address a few of the proposed changes that we feel are most important to urologists and the field of urology. We also encourage you to review other articles for updates to the Merit-based Incentive Payment System (MIPS)/Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and related value-based payment programs that affect your practice.

Due to the late release of this proposed rule, CMS has stated that it will invoke a protocol that allows late posting of the final rule only 30 days before it goes into effect on January 1, 2021. Thus, we project that the final rule will be released in late November or early December—which gives little time to react or prepare for any major additional changes posted in that final rule.

The process for comment on this proposed rule is unaffected by the late release and leaves time to read and react fully. The changes we discuss below may or may not warrant your individual action. However, a few of the proposed changes have a major negative impact on some specialties, and the reaction to some of the proposed rule changes has already begun. We will have to carefully watch the actions of Congress and President Donald Trump to attempt to anticipate changes that may impact the final rule.

As reported in the past, all changes to the PFS fall under a constraint of budget neutrality, and 2021 is no different. However, a number of specialties are arguing to change the impact of the changes by suspending or amending budget neutrality for this year. Any change of this magnitude will take an act of Congress. Although the circumstances are slightly different, we have played a similar waiting game before.

First and maybe most important, the change in evaluation and management (E/M) codes as related to their structure and value will likely have the most effect and may also be the most controversial change. Although everyone can agree that an update to E/M structure was needed regarding how it related to the modern practice of medicine, it is the revaluation that has garnered the most interest. Overall, E/M services will increase in value due to updates in the value of the work and practice expense. Because of the volume of services reported using these codes within the Medicare program, CMS is projecting an increase in the total number of relative value units (RVUs) for the next calendar year. In response, to keep budget neutrality, the conversion factor (used to calculate the payment for services based primarily upon the total RVU) is projected to drop by 10.6%.

Interestingly, even with the reduced value for professional fees of surgical services due to this conversion factor decrease, urology as a specialty is projected to see a bump of 8% in Medicare reimbursements. This projection is based on urologists as a group. Because not all urologists bill for the same services, individual urologists may be impacted differently.

The 8% projected increase for urology, along with increases for several other specialties (mainly those that perform a high number of E/M services), will come at the expense of specialties across the spectrum that bill more surgical or procedural services and fewer E/M services. This group includes many surgical specialties along with radiology, anesthesia, audiology, emergency medicine, infectious disease, chiropractic care, pathology, and most therapies. Those that are projected to gain include general practice, endocrinology, oncology, and rheumatology—with some increases in the double digits and some more than two times the increase for urology.

Predictably, those facing decreases are leading the charge to address the dramatic shift. For example, the Surgical Care Coalition is requesting an adjustment to the Medicare budget to allow the E/M code changes without the decrease in payments to other specialties. We have seen this before: For 9 years, CMS and Congress worked to avoid significant conversion factor decreases by “kicking the can down the road” with paybacks to the budget from future years. We will keep an eye on this to see what happens.

As mentioned, changes to the outpatient E/M code structure and valuation will have the most impact in 2021. The majority of the 2020 final rule as released by CMS remains unchanged and is scheduled to be implemented in 2021. You will likely recall that the American Medical Association has created new outpatient CPT E/M codes and guidelines for 2021. CMS has reaffirmed that they will adopt these changes as well as the value changes proposed by the Relative Value Scale Update Committee (RUC) with a few minor changes, such as the use of the 15-minute add-on code if using time for code selection.

The changes will only affect outpatient visit codes and will include the following:

• Documentation requirements: The history and physical examination section bullet point requirements will be eliminated and will require only a medically appropriate history and physical examination.

• Medical decision-making: Definitions and corresponding level requirements will be further defined and amended to more closely reflect clinical efforts for each level.

• Time values and time definitions: Time will no longer be counted by face-to-face time when more than 50% is counseling and coordinating care. Rather, it will be the additive time of the entire time on the date of service that the provider spends on the patient’s care, including previsit, intravisit, and postvisit time.

• Value increase for each level for codes 99202-99205 and 99211-99215: This increase will be reflected in both the work and practice expense components.

• New shorter prolonged services add-on code that measures time in 15-minute increments: This will be used with codes 99205 or 99215 when the total time the provider spends on the patient on the date of service exceeds the maximum time allowed by 15 minutes or more.

• New proposed HCPCS G-code: The GCP1x add-on code will be used to better describe the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. If finalized, the details of GCP1x will be better defined.

These are the first major changes to E/M codes in 23 years. Urology practices rely heavily on this set of codes for income. To prepare for these changes, each practice will need to reevaluate their previsit requirements for both patients and staff, implement a transition plan to address changing electronic health record templates and calculators, explore schedule and patient flow changes, project financial changes, amend compliance programs, and train personnel appropriately. A number of training programs will be available later this year.

E/M code values are not the only changes contributing to urology’s projected reimbursement increase. The practice expense of many high-volume in-office urology procedures is going up, which may help offset the proposed 10.6% conversion factor drop. Notable practice expense increases include urodynamics, UroLift, Rezum, cystoscopy, and cystoscopy-based procedures, including biopsy of the bladder and treating small bladder tumors.

The changes to work RVUs are minimal, granting a reprieve to urologists paid on work RVU production, which is good news short term. However, the decrease in the conversion factor will negatively impact the professional fees of procedures/services by as much as 10.6%, which is especially challenging when provided in house because the practice expense value for that facility bumps up a bit. This decrease may negatively impact the income of employers whose physicians provide services in the facility setting. RVU-based contracts will need monitored for reindexing to mimic payments from Medicare and/or private payers.

CMS has proposed shifting more of the balance of MIPS onto the cost portion, which is slated to increase from the current 15% to the new level of 20%, along with increasing the threshold minimum score from the 45 points to 50 points.

The proposed rule is written to accommodate the current public health emergency (PHE). The rule includes a number of provisions to indicate that the PHE will likely be renewed for at least 1 additional 90-day period. Currently, the PHE is scheduled to end on October 23, 2020. The PHE can be extended in successive 90-day terms. Many provisions for the 2021 proposed rule are written to extend through the end of the calendar year in which the PHE expires to allow for tracking and study of the services provided via telehealth, indicating that CMS expects the PHE to extend into 2021.

We will not take the time in this article to cover the many changes that Medicare made to telehealth in the face of the PHE. It is important to note that CMS has acknowledged the success of telehealth and will attempt to keep many of the changes in place after the PHE ends. CMS has added a number of codes to the permanent covered service list for telehealth and has indicated that some remote supervision rules implemented during the PHE will be adopted.

The proposed rule also indicates that CMS will add a third temporary category of services that will be considered covered through the end of the calendar year in which the PHE ends. Extending the use of these codes will allow Medicare to test their utility.

Medicare has further attempted to clarify both communication technology–based services (CTBS) and remote monitoring services to increase the use of both and to continue to address the lack of health care access for many Americans. New proposed CTBS codes for therapists and other professionals not qualified to bill E/M service will allow for remote check-in and image review services similar to codes G2010 and G2012.

CMS has also clarified requirements for remote physiologic monitoring and care coordination for codes 99453, 99454, 99091, and 99457. These clarifications indicate that after the PHE ends, (1) services can only be provided to established patients, (2) codes 99353 and 99354 will require data monitoring for at least 16 days within a 30-day period, and (3) code 99457 will require synchronous communication with the patient for at least 20 minutes in a 30-day period. Code 99091 is to be used to report the analysis of data obtained from remote monitoring, which is reported separately from treatment planning (code 99457).

The rule indicates that telephone-only codes 99441-99443 will not be covered after the PHE has ended; however, CMS has indicated a willingness to hear from patients and physicians with regard to the importance of telephone-only services. We would encourage you to contact CMS, your state medical society, and/or your senators and representatives to encourage the continued coverage of these service types.

All these rules clearly reflect efforts by CMS to increase the reach of telehealth and remote care. However, Medicare by rule cannot extend coverage for telehealth beyond what is allowed by law. For example, after the PHE ends, Medicare cannot cover telehealth services when the patient is at home. As such, without action by Congress, Medicare beneficiaries will be required to go to a Medicare-approved facility to receive telehealth services after the PHE ends. CTBS and remote monitoring services can be provided in a home-based setting but must follow the rules established by the program.

Again, we encourage you to contact your members of Congress and to encourage your patients to do the same to request that Medicare rules be changed to allow patients to receive telehealth from home. Currently, regulations are written in a way that indicate that the PHE is expected to extend into 2021.

We are all interested to see what changes may take place between this proposed rule and the final rule. In the meantime, we should all start preparing for 2021 with these proposed changes in mind.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Articles

Also watch for practice expense increases for many high-volume procedures.

2021 proposed rule: Get ready for E/M changes

If you perform a bladder scan and the residual is 0 mL, can you still charge for the bladder scan?

Yes, you can bill for a bladder scan even if the residual is 0 mL—if the indication for checking the postvoid residual (PVR) was medically necessary and the results are used in patient management. If at any time the goal of performing a test is to acquire data that can assist in patient management, and it is medically necessary and appropriate, it is a billable service. For example, if a patient with a history of kidney stones has flank pain and was ordered for a renal 

ultrasound, the service would be billed even if the patient ended up not having a stone. Please remember that medical necessity is the overarching criteria for billing any service, so there must be a medically necessary reason for checking the PVR. It cannot be done merely because the patient arrives in a urologist’s office.

Send coding and reimbursement questions to Rubenstein and Painter c/o

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

"If at any time the goal of performing a test is to acquire data that can assist in patient management, and it is medically necessary and appropriate, it is a billable service," write Jonathan Rubenstein, MD, and Mark Painter.

Can you bill for a bladder scan if residual is 0 mL?

The following operative report was submitted: “A rigid cystoscope was used to intubate the meatus. The stent protruding from the left ureteral orifice was grasped with flexible grasper and brought to the meatus. A wire was inserted through the stent and the stent was removed. A flexible ureteroscope was advanced into the ureter and the 200-μm holmium laser fiber was used to fragment the ureter stone. Once this stone was treated, nephroscopy was performed and the holmium laser was used to laser the 3-mm calculus in the interpolar region of the kidney and also 2 calculi of 6 mm in the lower pole. A zero-tipped basket was used to retrieve the fragments. The ureteroscope was slowly withdrawn and no other calculi were seen in the ureter. The ureter was very dilated from the previously placed ureteral stent, and I elected not to place a new stent.”

The insurance carrier follows Medicare’s Medical Unlikely Edits (MUEs) and therefore will not pay for two 52523 codes in the same surgery. Our coders attached the code of 52353-LT to the claim and passed edit. Our provider read an article where one stone was lasered and the other was extracted with a basket and the XS modifier was used on the basket extraction procedure, and therefore the provider is insisting that the XS modifier be used. Please clarify your interpretation of the operative note and the potential use of XS when only 1 CPT code is submitted. We could not bill the stent removal as it was bundled in with the 52353. I appreciate your assistance in this.

When reviewing this operative note, it appears that the patient presented with a ureteral calculus 

and also a few renal calculi, and they had been previously stented. You are correct that CPT code 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) is bundled to CPT code 52353 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy), so it cannot be billed separately. Therefore, CPT 52353 is the correct code to use for the lithotripsy of the ureteral calculus if a stent was not 

It is clear from the note you provided that 52353 was performed on 2 separate locations, if one interprets the ureter being a different location from the kidney. Your comment about this insurer following Medicare MUEs seems to be the problem you are bumping up against here. We have included a screen shot from the AUACodingToday website (

You can see from the red call-out box that the National Correct Coding Initiative (NCCI) lists the MUE as 1 under practitioner and with an adjudication modifier (MAI) of 2. Under Medicare rules (and this insurer, according to your question), Medicare will allow only 1 unit for the code to be reported on the same date of service. Anything above 1 unit will result in a denial. The rules apply to the entire claim and therefore, you are receiving an appropriate denial per Medicare NCCI instructions. You may be asking now, “How can I report a bilateral procedure if only 1 unit is allowed per date of service?” Medicare instructs that appropriate reporting of a code with an MUE of 1 and an MAI of 2 for bilateral services would be to report the code with modifier –50 with one (1) in the units box.

Note that if you were to review different codes, such as 52356 and 52353-XS, on the same claim, it would likely process for payment. MUEs apply on to the same code and with an MAI of 2 would only apply for that date of service. As 52356 and 52353 are listed as unbundling allowed with a modifier, and –XS is an appropriate code for the circumstances listed above, you could be paid for 2 laser stone treatments on the same side. We say “likely” to process for payment because, as we noted in our February “Coding Q&A” column

 CPT includes a note to this effect, which is also noted in the figure. Thus, billing for separate lasers on the same side would go against CPT rules when reported with 52353 and 52356, which a payer has the choice to enforce or ignore; this is an unfortunate rule that, in our opinion, does not allow for accurate compensation of the urologist for the work performed This leaves only modifier –22—“unusual service or procedure with manual review and variable treatment by payers”—as the only option for those providers whose payers follow NCCI and MUEs as a hope to get paid appropriately for the work performed.

You also mention above that a stone fragment was removed, which is reflected in code 52352 (stone manipulation). This code would be unaffected by MUEs for 52353; however, this opens up a second set of problems related to the definition of global and treatment guidelines in a separate section of Medicare rules. Your listing above indicates that the 52352 was used in follow-up to code 52353 to extract leftover fragments, implying that the manipulation was a part of the global of 52353 during that operative session. If, on the other hand, you indicated that the ureteral stone had been grasped and removed, this would have been considered “separate and distinct” from the laser stone treatment in the kidney and reporting with –XS would be appropriate and should be paid and supported with record review of the services.

1. Rubenstein J, Painter M. Stone moves to kidney during URS; how should I bill? 

®. February 25, 2020. Accessed July 20, 2020. 

ttps://www.urologytimes.com/view/stone-moves-kidney-during-urs-how-should-i-bill

Jonathan Rubenstein, MD, and Mark Painter tackle a question regarding billing for a stone procedure.

Stone procedure: Can XS modifier be used when only 1 CPT code is submitted?

Is there is a modifier for telehealth visits when more than 30 minutes are spent with a patient? For instance, what about when time is spent explaining options to a patient with newly diagnosed prostate cancer or when a new patient has complex issues to be discussed?

This is a great question, and for the purposes of this answer, we are assuming that you are describing a virtual visit service provided in the outpatient setting with a patient who is located in their home or at another nonoffice and non-facility/originating site. As of this writing, there are no specific evaluation and management (E/M) codes for those types of telehealth visits, but during this recent public health emergency (PHE) and hopefully afterward, many insurers (including Medicare) are allowing these services to be reported using the typical in-person office and other outpatient site of service E/M codes: 99201-99205 for new patients and 99211-99215 for established patients. Therefore, the same rules for selecting a code will be used for a virtual visit as for an in-person visit.

If using time for code selection, the current (1997) E/M guidelines direct you to choose a code based upon the time spent face-to-face with the patient, if more than 50% of the time was spent counseling and coordinating care. For example, in the case of a new patient, the code 99205 would be chosen for 60 minutes of face-to-face time, while the established patient code 99215 is for 40 minutes of face-to-face time. This will change slightly with the introduction of the new 2021 E/M guidelines; then, time will be chosen based upon the total time spent on the patient that day, including previsit, visit, and postvisit time. During this PHE, Medicare went ahead and implemented these time guidelines for telehealth visits only.

If the time of visit exceeds the time of the highest level of service (99205 and 99215), prolonged service codes can be used to report these exceptional circumstances. For the first hour, use CPT code 99354 (prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service]). Use 99355 for each additional 30 minutes.

CPT code 99354 can be added on to codes 99205 and 99215 for the first hour of additional time, and it can be used when the time exceeds the maximum time by at least 31 minutes. For example, you can bill CPT codes 99215 and 99354 for a face-to-face time of 71 minutes (40 minutes, plus a minimum of 31 minutes into the first additional hour of 99354). CPT code 99355 can be added on to the first 2 codes for each additional 30 minutes, if you reached 16 minutes past the first additional hour, which, for example, is 136 minutes for 99215 (40 plus 60 plus 16). The exact time in minutes must be documented in the note.

Of course, you will need to report appropriate place-of-service codes and modifiers to indicate that the visit was a telehealth encounter.

When the new E/M guidelines are implemented in January 2021, a prolonged service code for each 15 minutes of work above the maximum time for 99215 and 99205 has been proposed. The details of this code will likely be found in the Proposed and Final Rules for the Medicare Physicians Fee Schedule, which have not yet been released at press time.

 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, Towson, Maryland. 

 is CEO of PRS Urology SC in Denver, Colorado.

Send coding and reimbursement questions to Rubenstein and Painter c/o 

E/M guidelines direct code selection based on face-to-face time with patient.

Author | Jonathan Rubenstein, MD

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2021 proposed rule: Get ready for E/M changes

Can you bill for a bladder scan if residual is 0 mL?

Stone procedure: Can XS modifier be used when only 1 CPT code is submitted?

Urology Practice: How do you bill for virtual visits lasting more than 30 minutes?