Jonathan Rubenstein, MD

As 2020 winds down, typically everyone from newscasters to sports reporters to anyone with a Twitter handle will write a “Year in Review” article, adding their predictions for the upcoming year. So we thought we would do the same—take a look back and also a look ahead.

2020 has been a fascinating year. The public health emergency (PHE) due to coronavirus disease 2019 (COVID-19) threw a huge curveball to the planet, including the delivery of medical care. All medical practices were affected. There was an explosion of telemedicine. We saw restrictions in elective surgeries, the barring of loved ones from visiting patients in hospitals, and numerous protections put in place.

® end-of-year article would have provided updates on the final rule for the 2021 Medicare Physician Fee Schedule, as we would have had time to review the document and alert providers of changes they would need to make in their practices. But due to the PHE, the final rule will not be released until after this article has been written. The Centers for Medicare & Medicaid Services (CMS) is running behind on several fronts. As we look forward, we are not going to stick with predictions but instead provide a series of goals and actions to reach those goals.

Relative value unit and conversion factor changes

As evaluation and management (E/M) code changes are due to take place on January 1, 2021, which will represent the first major change since 1997, there is a projected 8% increase in payments to urology, based on the increase in valuation of E/M codes. In addition, there is a new add-on Healthcare Common Procedure Coding System code (GPC1X) for patients with diseases that require an ongoing relationship with a urologist that will be able to be used with patients on Medicare. Finally, there is an increase in many practice expense values for services performed in the office.

The increase, however, comes with a price; specifically, a decrease in the Medicare Conversion Factor by 10.6%, due to budget neutrality. This will result in lower payments in 2021 for most medical services outside of E/M codes. The decreased conversion factor also will result in payment decreases for many other specialties, including anesthesiology, radiology, pathology, therapists, and most of the surgical specialties. There are a few proposals to stop this dramatic shift in payments, including a proposal to suspend budget neutrality for next year.

Our hope is that CMS and the US Congress will act to suspend budget neutrality for this year at least, with legislation that does not kick funding down the road, sending us down a path of eternal conversion factor reduction threat similar to the years prior to the Medicare Access and CHIP Reauthorization Act of 2015. As this will require an act of Congress, we encourage you to contact your senators and representatives and encourage them to suspend budget neutrality for 2021 to help health care providers recover from the PHE.

The majority of medical providers and a significant number of patients became fans of telemedicine in 2020, citing its convenience and practicality. Luckily for many of us, Medicare appears to also be a fan of telemedicine. Patients have enjoyed the experience. Many physicians have found a place for telehealth during the PHE with equal pay for services rendered. During the PHE, Medicare has covered telephone-only services at reasonable rates to allow for services to patients without technology services or ability. Medicare also has expanded remote patient monitoring services.

Although we can appreciate the changes that Medicare is proposing in an effort to add telehealth as a treatment path for many patients, we note that they have not been able to go far enough. When the PHE ends, many of these services will not be supported in way that will make telehealth a truly viable treatment option for many patients and circumstances.

Our desire is to see fair reimbursement, continued expansion of these services, and the ability to treat patients while they are at home, regardless of where they live.

In the proposed rule, Medicare has indicated a desire to keep or even expand some of these services but not others. For services such as telephone-only support that Medicare does intend to cover after the PHE ends, we encourage you to continue to support the American Urological Association, American Medical Association, and other groups lobbying for these services to be extended permanently.

If Medicare is going to truly make telehealth a viable service option, we need new legislation. We would encourage you to also mention expansion of telehealth services for patients in their home at rates comparable to in-office services when you contact your senators and representatives about the conversion factor.

As we have written about and provided instructions to urologists around the country, we have become even bigger fans of the updated E/M outpatient codes. Although change is never as easy as we would like it to be, we are confident that those who embrace the changes and break through the initial learning curve also will realize the benefits to patients, providers, and practices.

Our hope is that providers embrace these changes. Anyone involved in patient care should get appropriate training, study a little bit, and become a student of the practice. Jump in with both feet early and keep an open mind.

The changes to the E/M codes are going to allow providers to stop all the unnecessary clicking and “note bloat” seen when trying to meet the coding guideline rules, and instead allow providers to get back to their expertise: patient care. Practices should change their patient intake forms to focus on the medically necessary data needed without having to collect information no longer needed or relevant. Shortening these forms will not only make patients happy but also will allow practices to have a more efficient workflow, taking pressure off of front desk and other support staff struggling to set up or update the medical records. If done correctly, staff can be freed to focus on the patient experience, tracking services can be provided, and the stress in the office will decrease.

Physicians then will be more able to focus on clinical services, reduce time spent with the electronic health record, and develop notes that can be understood by patients and other medical professionals. In addition, the services will be more able to be accurately reported to better reflect the appropriate level of service chosen.

For a minimal investment of time, we hope providers enjoy these changes.

Although our hopes are not all guaranteed to pan out, we again encourage everyone to take action where they can. Learn the new E/M system. Get involved with advocacy. Even a small investment in time may indeed bring about changes to make 2021 and beyond a more pleasant experience for all.

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

Evaluation/management changes should benefit providers and patients.

How urology coding changed in 2020—and what to watch for in 2021

With the new evaluation and management changes for 2021, should I expect to be billing the same levels as before, or do you anticipate any changes due to the new Medical Decision Making section?

This is a great question. Although we have all heard that with the new evaluation and management (E/M) guidelines slated to start on January 1, 2021, overall, urologists will see a bit of a boost in reimbursements due to the increased relative value unit (RVU) of the majority of office E/M codes, and therefore increased payments, that would hold true if year-after-year there were the same E/M services billed (the same number of 99213s, the same number of 99214s, etc).

However, as with any new system, there are likely to be some shifts around, as the Medical Decision Making (MDM) section (which is used to determine the E/M level if time is not chosen to report the service) has changed a bit. The main changes take place in the Complexity of Problem and Amount/Complexity of Data sections. By looking through a number of charts, we do see 

some areas where there will be some shifts. Although not scientifically studied, when reviewing a number of charts and projecting the reported code under the new 2021 guidelines in comparison to current code levels selected, we found that the majority remained unchanged. For those codes that changed, we estimated a level neutral change, meaning the number of codes that went down in level were roughly offset by the number of codes that went up in level. That may not be true for all urologists due to their own individual practices. Here is how we figured that out and how we anticipate some of the shifts to occur.

Number and Complexity of Problems Addressed section of MDM.

 In the 1995/1997 system, points would be added for each condition managed on that date of service, and the sum of the points would determine the level for that section. For example, the provider would get 1 point for each established stable problem, 2 points for an established worsening problem, 3 points for a new problem that does not require further workup, and 4 points for a new problem that requires further workup.

In the 2021 system, this changes. No longer will the problems be summed to reach a final level, but rather the acuity of the illness(es) and the way that the problems affect patient management will determine patient complexity. This change was added to address the few physicians who would stack diagnoses or document in the chart diagnoses/problems that were not medically necessary to address on that day. In the new system, a patient with 1 self-limited or minor problem would still reach a level 2 in 2021, and 2 minor problems would still reach a level 3. In those encounters for which a chronic illness/problem that is worsening is addressed, a level 3 would be reached in the old system; under the 2021 guidelines, it would reach level 4 for this element of MDM. However, one can only reach level 5 if a patient has a severe exacerbation or a threat to bodily function in the 2021 system, regardless of the number of problems addressed.

Amount and/or Complexity of Data to be Reviewed and Analyzed section of MDM. 

Similarly, instead of getting 1 or 2 points for a variety of data types (review and/or order radiology tests/labs/medicine test, obtaining old records, summarizing old records or discussing with another provider, independent visualization of image or specimen), and adding them together, in the new system, again, the way the data is used and how it affect patient management determines the final data level. CPT has added a few clarifying statements as to what counts as data, when it is appropriate to use data as part of MDM and how to consider data as it pertains to each level of code. The clarifications include a specific reference to data included based on each CPT code test for specific data types and the exclusion of data for which you are separately paid for interpretation. It doesn’t necessarily take more or less data to reach certain levels, but what is more important is not the volume of data but the importance of the data, the amount of effort and expertise it takes to interpret the data, and the way that data affects patient care.

The table itself is the section that has changed the least and is in essence the merge of the Diagnostic procedure(s) ordered and Management Options Selected subsections, with Presenting Problem(s) subsection eliminated. Therefore, those who would use the selections on the 2 subsections that remain would find the table unchanged, but those who would use the Presenting Problems subsection would not be able to use that portion on the Table of risk.

So what does this mean? Ultimately, there will be some shifts of patients around between the levels, but it appears on a high level that the overall levels selected would remain unchanged for those who were using the MDM chart correctly. We encourage you to review the changes and seek some additional training. In the long run, these changes are good for the clinician and good for patient care, reducing the amount of clutter in the office note and the work required to add this information.

We would like to add a note to our recent Q&A article with regard to the use of code 99091.

 In our discussion, we wrote, “ ‘Incident to’ services provided by staff and conforming to Medicare guidelines may also be included to assist in the collection and interpretation of data.” We based this information on information included in the proposed rule for the 2021 Medicare Physician Fee Schedule. As we also noted, the description in the CPT coding manual would imply that Physician or a Qualified Healthcare Provider time is required for inclusion in the 30 minutes spent in remote data collection and interpretation. We are going to add a note of caution here as the statement we included was in fact based on a proposed rule interpretation and not a final rule or CPT note. Medicare may not accept the medical assistant or other assistant time in the 30-minute calculation even if the time was spent within “incident to” rules.

1. Rubenstein J, Painter M. What to know about reporting CPT code 99072. 

. October 14, 2020. Accessed October 23, 2020. 

https://www.urologytimes.com/view/what-to-know-about-covid-19-cpt-code-99072-for-your-urology-practice

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.

"The main [Medical Decision Making section] changes take place in the Complexity of Problem and Amount/Complexity of Data sections," write Jonathan Rubenstein, MD, and Mark Painter.

Coding Q&A: How will Medical Decision Making change for urologists in 2021?

What is the correct coding for a patient who has a stent removed with an externally accessible dangle or if a cystoscopy is performed to remove a dangle within the urethra?

There are a number of CPT codes that can be used to bill the work to remove a stent from a patient depending on the situation, and there are times when no separate CPT code exists and the work for removing a stent is included in the office visit.

Let’s start with the first situation: a “dangle” attached to the stent is used for removal of the stent. There is no CPT code to describe the situation when a patient has a stent removed with an externally accessible component such as a string or dangle. The work of removing a stent in this manner is included in the evaluation and management visit.

In the situation where the dangle is still within the urethra and a cystoscope is used to perform urethroscopy and a grasper is used to grab the dangle for removal, use CPT code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).

There are some who may be tempted to use CPT code 50386 (Removal [via snare/capture] of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation) to remove a stent on a dangle that is within the urethra using an instrument to grasp the non-visualized dangle without the use of cystoscopy. However, CPT code 50386 is located in the ureter section of the CPT code book. As the full description implies through its location in the CPT manual and the description, the removal of internally indwelling stent reported with this code would require the use of a snare or capture to directly grasp and remove the stent without the use of a cystoscope. The inclusion statement “including radiological supervision and interpretation” refers to the fact that the procedure would usually require radiologic guidance for the capture or snare to guide the instrument to the stent without the use of the cystoscope. The inclusion would also prevent the separate reporting of a radiological guidance code such as fluoroscopy.

It should also be noted that the relative value units (RVUs) for 50386 were based on the average case reported for the code, which included the use of anesthesia and imaging to place a rigid biopsy forceps into the bladder to remove the stent. Understanding the average case used to develop the RVU provides some additional insight into the intention of the code and can be used by payers to determine appropriate code usage in a chart review.

Despite the fact that anesthesia and radiologic supervision are not required within the description of the code itself, if you are snaring or capturing a dangle in the urethra and remove the stent in this manner, you have not met the definition of code 50386.

Unfortunately, we do not have an accurate code to report a removal of a stent in this manner. Similar to a stent removed via an externally accessible dangle or a catheter, we would recommend including the removal of the stent via a dangle snared in the urethra in an evaluation and management code or reporting the service with an unlisted code.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o 

Use CPT code 52310 when a dangle is within the urethra and a grasper is used.

What are your options for billing for ureteral stent removal?

What is the story with the new CPT code 99072?

Payment for the typical resources, supplies, and clinical staff time and effort is included in the value of evaluation and management (E/M) visits and other medical visits. However, up until now there was no code available that could be used to report the additional expenses incurred by practices for the extra supplies, materials, and clinical staff time needed to mitigate the transmission of coronavirus disease 2019 (COVID-19).

CPT code 99072 was created by the CPT Editorial Panel in response to these extra practice expenses associated with patient care during the Public Health Emergency (PHE). Practices can use CPT 99072 to report the additional materials, such as extra cleaning supplies; face masks; personal protective equipment; thermometers; and clinical staff time, including, but not limited to, previsit instructions and office arrival symptom checks, that support the safe provision of 

evaluation, treatment, or procedural service during this unprecedented time. Practices may use this code in conjunction with office visits and other nonfacility services when the office visit or other nonfacility services are rendered during the PHE, as defined by law, if the practice itself incurs such expenses. Unless extended, the current PHE for COVID-19 is scheduled to expire on October 25, 2020.

When reporting CPT code 99072, practices should report the code only once per in-person patient encounter per day regardless of the number of services rendered at that encounter. Code 99072 may be reported during a PHE when the additional clinical staff duties as described are performed by the physician or other qualified health care professional in lieu of clinical staff.

Use CPT 99072 only when safety measures are over and above those usually included during an office visit or service, as opposed to CPT code 99070, which covers supplies, materials, and time used during a typical office visit.

Additional coding guidelines for 99072 include the following:

• The time counted in any other time-based visit or service during the same encounter cannot be counted twice to report this code.

• You do not need to link the code to a particular diagnosis code such as ICD-10-CM U07.1 COVID-19.

• You may report 99072 with an E/M service or procedure even if it is not PHE-related.

• You may report 99072 only once per in-person patient encounter per Provider Identification Number (PIN).

Note that, as of this writing, there has been no definitive payment for CPT code 99072, so it is important that physicians check with their Medicare contractors and insurance carriers.

CPT code 99072 was created in response to extra medical practice expenses associated with patient care during the pandemic. 

Jonathan Rubenstein, MD

Articles

How urology coding changed in 2020—and what to watch for in 2021

Coding Q&A: How will Medical Decision Making change for urologists in 2021?

What are your options for billing for ureteral stent removal?

What to know about COVID-19 CPT code 99072 for your urology practice