My private practice is part time, and I have opted out of all private payers, remaining only in Medicare. However, I am thinking of opting out of Medicare as well. I also do locum tenens work, but the hospital does all the billing and I receive nothing from CMS, so I’m assuming my services are billed through the hospital. My question: If I opt out of Medicare in my private practice, does it affect any billing from any hospital that I work as a locum?

If you opt out of Medicare, you are required to sign an affidavit in which you agree to a number of specific conditions, including:

“State that physician/practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during opt out period, nor will physician/practitioner permit any entity acting on his/her behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary, except for emergency and urgent care services provided to a Medicare beneficiary with whom he/she has not signed a private contract.”

We provide two general situations for consideration. 

 You are providing urology services to patients of the hospital during specified periods on an intermittent basis throughout the year. When you are not in town, there is either no urologist in town or there is another urologist who is also providing coverage as you do on an intermittent basis. In short, you are providing urology services to the patient population on behalf of the hospital, but not covering for another physician.

If you opt out of Medicare, Medicare will not pay for any service reported under your National Provider Identifier (NPI). Under this scenario, it would appear that the hospital is reporting your services to Medicare and receives payment for those services under your NPI as the rendering provider. The hospital would not be able to bill for your services.

However, Medicare would continue to pay the hospital for any services you have ordered and services the hospital provided, such as hospitalizations, OR time, imaging, lab studies etc., if you have supplied your Social Security number and NPI on the optout affidavit.

Also by Ray Painter, MD, and Mark Painter -

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You are providing services to an area that is normally served by a physician for whom you are being hired for a period of less than 60 days to cover for. (This period can be longer if the “regular” physician has been called to active duty military service.)

This situation is a bit more difficult. We received multiple opinions when researching this situation.

An optout physician was not precluded from billing under a contracted arrangement in which the physician was paid solely on time worked and services were reported with modifier –Q5 appended to the service with the regular provider’s NPI as the rendering physician. The regular provider is required to maintain a record of the covering physician’s NPI and credentials.

The optout provider status would continue to pose a problem, as the affidavit prohibits billing Medicare for any services provided.

In the end, we encourage you to seek legal opinion in your state for you and your potential employer before opting out. We would also encourage you to consider first moving to “non-par” (non-participating) status with Medicare for at least 1 year as a transition to optout status. As a non-par provider, you bill your patients directly for all services, and you can either ask the patient to bill Medicare or bill for the patient and the patient would receive payment from Medicare.

As a non-par provider, you are limited to a charge of 109% of Medicare allowed amount and must follow Medicare rules. The non-par status does, however, start you down the path to opting out of Medicare and will not affect your status with the hospital. Your contracting entity, hospital or other, could except assignment on any patient, but would be paid 5% less then if you were a participating Medicare provider.

My dad recently started bacillus Calmette-GuÃ©rin infusion therapy for his bladder cancer. He goes to his urologist’s office to get the catheter inserted by a nurse and then to the local hospital’s infusion center for the administration of the drug. He is on his second treatment. He recently got a bill for $200. It appears the hospital is billing his insurance a “surgical procedure” every time he goes in for an infusion. There is no surgical procedure. There is an injection into the catheter. No physician is present. I’m so baffled by this billing code. Can you please tell me how this procedure should be properly billed?

The correct CPT code for the instillation of BCG is 51720 (Bladder instillation of anticarcinogenic agent [including retention time]). And although there is no incision or anesthesia-what we typically think of as a surgical procedure-the service has been assigned a code within the surgical section of CPT and is assigned a global period that is treated by payers and physicians alike as a “surgical” service. The hospital charge/payment is based on a formula that allows the hospital to include typical supplies (whether or not they are used), personnel costs, and general overhead. The charge is based on the CPT code for the service and is often labeled as a surgical charge.

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Therefore, the reporting is at least partially accurate. The hospital should also report the BCG as a separate charge under code J9031.

Based on your description of the services, we would project the hospital charges to be as follows: 51720 and J9031.

The amount of charge and reimbursement would vary.

The answer provided here should apply to your situation, particularly if the physician is employed by the hospital in the hospital is billing for all services. However, if the physician is not employed by the hospital, you may receive an additional charge for the insertion of the catheter. That code may vary based on the arrangements between the physician and the hospital.

Reporting a simple laparoscopic prostatectomy

What is the correct way to report a simple laparoscopic prostatectomy? I was told to use the appropriate open code, but my compliance department tells me I should use the unlisted code. We have agreed to report based on your answer.

First, we will start with the obvious. There is no specific code for a simple laparoscopic prostatectomy. Therefore, using an unlisted code would not be inappropriate. That being said, we also think you have the option of using the appropriate open code.

The codes currently used to report open prostatectomy-55831 (Prostatectomy [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy]; retropubic, subtotal) and 55821 (Prostatectomy [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy]; suprapubic, subtotal)-do not specifically include that they have to be performed by an “open” procedure nor do they exclude the use of a laparoscope. The approach, open or laparoscopic, is not designated. Therefore, the codes could be used to report either approach.

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To add to the comfort of that decision, the AUA, in a Policy & Advocacy Brief, published the suggested coding as recommended by the AUA Coding and Reimbursement Committee. They recommended using the appropriate code 55831 or 55821 for the reasons stated above. AUA officials cannot set payment policy for CMS, but their opinions have a lot of influence. If you follow their advice, you will be safe from fraudulent billing claims, even though a payer may not agree with the recommendation.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at 

 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.

Articles

Ray Painter, MD, and Mark Painter also answer questions regarding BCG instillation and reporting of simple laparoscopic prostatectomy.

Does opting out of Medicare affect locum tenens billing?

Americans spent approximately $16 billion on cosmetic surgery in 2016, according to an American Society of Plastic Surgeons report. Traditionally, cosmetic surgeries have been popular among women, with approximately 90% of all cosmetic surgery cases performed in female patients. However, growth in the male aesthetics market has translated into increased interest in cosmetic surgical procedures 

 The male market has increased for several reasons: Shifting social attitudes, improved professional competitiveness, new trends in fashion, and the attainment of an idealized self are a few reasons most often cited in the literature 

Of concern is whether the increased demand for male cosmetic procedures is a passable trend or a lasting norm. Clinicians interested in servicing this new community will have to consider the benefits of shifting their practice in order to meet the demand for male-focused cosmetic procedures.

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In this article, we provide an overview of the key concepts a clinician must take into consideration when consulting with men interested in undergoing a cosmetic surgical procedure.

In order to understand what treatments men want and are eligible to receive, clinicians must first gain familiarity with the male pattern of aging. Males and females have distinct variations in anatomy, specifically in regards to bone structure, muscle mass, thickness of skin, and distribution of fat. In general, men have greater periocular changes as they age. They develop more severe rhytides (wrinkles) on the face, except around the mouth, and are more likely to experience hair loss.

As males have thicker skin and more muscle mass around their face, the loss of fat with age shows deeper and more prominent facial lines, making them appear much older than their actual age and their female counterparts 

 As men and women differ both in their anatomy and their goals for pursuing cosmetic surgery, it is important for clinicians to specialize their treatment, dosages, and technique accordingly 

It is also important to note significant behavioral differences between males and females. There are many external risk factors for aging including sunlight exposure, pollution, cigarette smoking, repetitive muscle movements, and poor diet, with the most common being ultraviolet light exposure and smoking 

 Men who smoke tend to smoke more than their female counterparts, which increases their risk for skin aging 

 Furthermore, men are more likely to be exposed to UV radiation and less likely than women to apply sunscreen and utilize sun-protective behaviors.

Physicians need to be more cognizant of these gender differences in behavior and how these behaviors affect overall patient management.

In a patient considering cosmetic surgery, it is crucial that physicians assess the patient’s goals and expectations. This includes a determination of the patient’s aesthetic goals. Typically, males want to look younger while also enhancing features to appear more masculine. However, there is a point at which an aesthetic can become too masculine and may be undesirable by the patient. Therefore, it is important for clinicians to determine what features are considered aesthetically appealing in advance. More often, this is crudely defined as a mixture of masculine and feminine facial features.

In general, males focus their facial cosmetic concerns around the hairline, periocular region, and jawline, according to statistics from the American Society for Aesthetic Plastic Surgery. Men want to maintain their scalp hair, tighten their jawline, reduce dark circles and bags under the eyes, and reduce the prominence of wrinkles. Men also want to maintain their figure by having a slim waistline and smaller breast size if they have gynecomastia 

Cosmetic surgery has also increased in males as a result of genitourinary concerns. Studies show that if a man feels negatively about his “genital self-image”-the way a man regards his genitals-it may affect his sexual performance. If men are anxious and worried about their genitals’ size, appearance, and function, the result could be increased anxiety and subsequent sexual dysfunction.

Research shows that approximately 20% of males are embarrassed or unsatisfied with the appearance of their genitals 

 As such, it is noted that the number of scrotal lift procedures, penile and testicular enhancements, and adult cosmetic circumcision procedures is also increasing.

A second consideration is the patient’s willingness to undergo intrusive therapies. Consideration for the degree of invasiveness tolerable by the patient will limit the degree to which the clinician is able to achieve the patient’s desired aesthetic. However, technological and technical advances are reshaping the extent of aesthetic change possible with noninvasive and minimally invasive techniques.

For example, over the last two decades, the way facial aesthetic procedures are typically performed has changed. Facial procedures were regularly completed in the operating room, but with the emergence of noninvasive techniques, many of these procedures can now be completed in an office setting. There has been a noticeable increase in nonsurgical procedures, such as botulinum toxin A (Botox, Dysport, Xeomin) injections, soft tissue fillers, and chemical peels 

The top five cosmetic surgical procedures for men in 2017 were liposuction, eyelid surgery, breast reduction, tummy tuck and facelift 

 In 2017, men accounted for 10% of all liposuction procedures, 15% of all eyelid surgeries, 22% of breast reduction cases, 6% of tummy tucks, and 10% of all facelift surgeries (Statistics: The American Society for Aesthetic Plastic Surgery. 2017. 

Minimally invasive procedures have increased in popularity among men as well. Over the last 5 years, there has been a 44% increase in injectables, with a 5% increase from 2016 to 2017. Of all the injectable procedures performed in 2017, men accounted for 9%, with botulinum toxin injections being the top nonsurgical procedure 

 (Statistics: The American Society for Aesthetic Plastic Surgery. 2017. 

 There has been a notable increase in nonsurgical cosmetic procedures, especially among men.

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In general, men prefer noninvasive cosmetic procedures, as they can be done in the office setting, are relatively quick, and deliver noticeable results. Minimally invasive procedures are suitable options for patients who want an alternative to surgery and often have the added benefit of producing a long-lasting patient-clinician relationship.

It is evident that although men are not the major consumer in the cosmetic industry, they are on track to become significant consumers of cosmetic procedures. Examination of data over the last two decades shows men are becoming an increasingly important sector of this industry, with greater attention paid in developing techniques and technologies to address the demands of this population.

As longevity increases, there will be greater societal focus on maintaining a healthy, youthful physical appearance. This interest will create novel opportunities for clinicians to develop and deliver novel cosmetic surgical solutions to address this demand. In the future, men may eventually surpass women as recipients of key cosmetic procedures.

 is assistant professor, division of urology, University Health Network, University of Toronto.  

 is professor of urology at the Icahn School of Medicine at Mount Sinai and director benign urologic diseases, Mount Sinai Health System, New York. Follow him on Twitter at 

Cosmetic surgery in men: Fad or new trend?

Since the 2014 publication of the AUA’s guideline on medical management of stone disease, studies have indicated low utilization of the document. In this interview, 

 discusses the guideline and also touches on disposable ureteroscopes and percutaneous access. Dr. Pearle is a professor with joint appointments in the department of urology and the Charles and Jane Pak Center for Mineral Metabolism and Clinical Research at UT Southwestern Medical Center, Dallas.

 professor of urology at Wake Forest Baptist Medical Center, Winston-Salem, NC.

You chaired the panel that developed the AUA guidelines on medical management of kidney stones. How well are these guidelines being followed today?

The results are somewhat disappointing, although I’m not sure we’ve really seen the full penetration of the guideline yet. One study looked at utilization of the guideline using the metric of 24-hour urine studies ordered in patients who had been diagnosed with a stone, although this came from an administrative dataset, rather than patient-level data. The numbers were pretty low-about 7% in a study that looked at patients presenting to the ED and being diagnosed with a stone for whom 24-hour urine studies were ordered within 6 months of the ED visit. When the authors looked at higher risk individuals, I think that number was only about 16%.

That is certainly lower than we would like to see. But the guideline came out in 2014, and my guess is that it takes a few more years to really see it start to change practice.

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The goal of the guideline was to try to create a document comprised of a set of guideline statements that would make the process of medical evaluation and management easy. I think clinicians look at it as a daunting task to evaluate stone patients medically. They don’t know who to evaluate, they don’t know what to evaluate, they don’t know what test to order, and then they don’t know what to do with the information they receive.

In addition, I think some urologists have concerns about prescribing medications, because the medications require careful follow-up and blood testing to monitor for side effects. But we’ve been prescribing medication in urology for decades whether it’s for BPH, erectile dysfunction, or cancer. We have to monitor those patients for side effects, with liver enzymes, complete blood count, or PSA. We are capable of monitoring patients for side effects of medications, and I think the same has to be done for medications aimed at stone prevention.

The guideline sets forth a fairly simple recipe to identify which patients should be evaluated, how we should evaluate them, how to treat them with diet and medication, and even broadly how they should be followed. For probably 95% of recurrent stone formers, these guidelines provide relatively straightforward recommendations for medical management. There are probably 5% of patients who are complex and will require more expertise and more testing, but I think the vast majority of stone patients can be well managed from this document.

"I think disposable ureteroscopes have a distinct place in our armamentarium."

Urology is all about technology and you’ve been on the forefront, especially in the area of ureteroscopy. What do you think about the disposable ureteroscope?

I think disposable ureteroscopes have a distinct place in our armamentarium. They have been shown to be safe, effective, and even cost-effective compared to some reusable digital ureteroscopes, although they are admittedly a little bigger and have an image quality that is inferior, although certainly acceptable for stone management.

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Processing and maintenance of flexible ureteroscopes, particularly digital flexible ureteroscopes, is labor intensive and costly, so for institutions or hospitals that do not perform large numbers of ureteroscopies and do not own a large array of scopes, it can be prohibitive to maintain these instruments. In those situations, I think a disposable flexible ureteroscope is a very useful device because it obviates the need for highly skilled workers to maintain these instruments.

In addition, having a disposable ureteroscope means that you never are without a functional ureteroscope. If your reusable scope breaks, you can always finish your case if you have a disposable ureteroscope available. There is clearly a role for them, whether it is for use in technically difficult cases that pose risk of damage to the ureteroscope, as a spare, or as a complete replacement for reusable ureteroscopes, and they will undoubtedly get even better with time.

How does the cost work out for disposable ureteroscopes?

Some studies have demonstrated that they can be cost-effective or at least cost neutral. It just depends on the setting in which they are used and the number of cases performed. However, I can imagine a model in which disposable scopes are cost-effective when you factor in the time and labor required to maintain the ureteroscope at your institution.

For years, there has been a debate on managing stones with ureteroscopy or extracorporeal shock wave lithotripsy. For a while, it looked like ureteroscopy was the way to go. Have there been second thoughts on this of late? Is ESWL making a comeback?

I don’t know that shock wave lithotripsy is making a comeback. By any number of metrics, whether it’s administrative datasets or case logs submitted to the American Board of Urology, ureteroscopy has definitely inched out shock wave lithotripsy as the most commonly performed stone procedure. Percutaneous nephrolithotomy remains under 10% and ureteroscopy is probably more like 60% versus 30% for shock wave lithotripsy. Younger urologists use ureteroscopy more than shock wave lithotripsy, and you can see how that trend has changed over time.

I think the change in utilization is because shock wave lithotripsy technology has been disappointingly stagnant, while ureteroscopy technology and technique have really advanced. We have better ureteroscopes, and we have technically gotten better at performing ureteroscopy. There are very few kidneys and stones that we are unable to access with a flexible ureteroscope and virtually no stones that we can’t fragment with a holmium laser. Access really isn’t an issue anymore.

But what we’re starting to look at now is effectiveness. With shock wave lithotripsy, we went through a period of time when it was first introduced in which the technology was used indiscriminately for all types and sizes of stones. Over time, we became more selective and started to identify patient subgroups for whom SWL was more or less effective. Now, we have refined patient selection such that we enrich the treated patient population with shock wave lithotripsy with those who are highly likely to have a successful outcome.

We now know that patients with lower pole stones greater than a centimeter should not be treated with shock wave lithotripsy. We also have certain CT parameters that we can use to identify patients who are likely to have a successful outcome.

We haven’t done that extensively yet with ureteroscopy. We are in a “lovefest” with ureteroscopy right now by which we are treating bigger and more complex stones, even partial staghorn calculi, ureteroscopically. But I think it is not a matter of “can we?” but “should we?” Are we doing patients a favor by doing so?

As we have been increasingly scrutinizing ureteroscopy outcomes using more sensitive imaging modalities like CT that detect residual fragments more accurately than KUB or ultrasound, we are finding that the stone-free rates with ureteroscopy aren’t as good as we thought. We are finding across the board with prospective and retrospective studies that ureteroscopy for stones in the kidney and ureter have about 50%-55% stone-free rates by CT, which is not that much better than shock wave lithotripsy, although we have never really subjected shock wave lithotripsy to the scrutiny of CT imaging.

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I don’t know that we are going to ever revert back to the utilization of SWL that we saw in the past, but I also don’t know that ureteroscope is the answer we are ultimately looking for. There may be a narrower group of patients who can be effectively treated ureteroscopically, and for those other patients, we may need look at other technologies like mini-PERC that possibly can achieve better stone-free rates, particularly for medium-sized stones. Standard PCNL still remains the gold standard for stones that are larger than 2 cm. But patients with 1- to 2-cm stones may comprise the subgroup for whom the treatment algorithm may need to change.

"Access is the biggest barrier to performing PCNL."

In my travels across the world, I’ve observed that PCNL access by urologists is much better outside the United States. In the U.S., it has not crossed the 10% mark that we’ve been talking about for years.

That is absolutely true. We have really lagged behind other countries in obtaining our own access. I think there are a number of barriers. In a lot of training programs, even endourology fellowship programs, residents or fellows did not learn percutaneous access if access was not obtained by the program director. However, it is required in our fellowships, so if mentors do not gain access themselves, then the fellows have to be exposed to interventional radiologists who can teach them how to obtain percutaneous access. As the residents and fellows learn more, hopefully they will carry that into practice with them.

Access is the biggest barrier to performing PCNL. It is what prevents practitioners from treating large stones appropriately and to force SWL and ureteroscopy treatment for stone sizes for which they are ill-suited. If we incorporated percutaneous access better into our residency and fellowship programs, those barriers would quickly fall.

There has been a surge in ultrasound-guided percutaneous access, and we in the U.S. have also been late to this trend. Now, there is a lot of interest here in learning ultrasound-guided access, which I suspect will help break down some of the barriers.

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Some argue that if you do less than 10 percutaneous procedures in a year, you will never become proficient. But as you learn to do it, you find more indications for it than you do currently. Anyone who starts doing PCNL, whether in private practice or not, if stones make up the entirety of your practice, you will find indications for the procedure if you know how to do it.

What are your thoughts on robotic ureteroscopy?

I like the thought of robotic ureteroscopy. I’m jealous of my partners who do robotic surgery, because when I walk into their ORs, they are comfortably sitting at the computer with their shoes off, no gown or gloves. They don’t suffer from back, neck, or wrist problems. I would be happy to be more comfortable when I operate, too, and I believe a robot can operate a ureteroscope better than my limited hands. Of course, there are some tasks that require haptic feedback, like placing an access sheath, that will require careful integration. But I believe there is a role for robotic ureteroscopy, and I look forward to seeing these platforms develop.

Thoughts on the state of women in urology

Please give your thoughts on the state of women in urology.

I am very proud to have served in leadership roles within urology and endourology, and I do see a trend in which women are assuming more and more leadership roles. A recent study in 

indicated that 10% of leadership positions in urologic/subspecialty societies are occupied by women 

 Ten percent is fairly consistent with the percentage of women in urology, so although women overall are underrepresented in urology, they may be appropriately proportionately in leadership roles at this time.

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However, the hope is that both of those will increase with time as more and more women enter into urology. Among younger women, we are seeing greater numbers in urology, and hopefully we will see that reflected in leadership roles.

Most organizations are making efforts to include women on their boards and in their leadership structure. Clearly, we have a long way to go. But as more women reach leadership positions, I suspect we will see more changes at the ground level and vice versa. I am thrilled to see that Dr. Ann Gormley has become the first woman on the AUA Board of Directors, and I hope at some point she might become our first female AUA president. That is a day I hope to be around to see.

In this interview, Margaret S. Pearle, MD, PhD, discusses the AUA’s guideline on medical management of stone disease and also touches on disposable ureteroscopes and percutaneous access.

Stone disease field marked by advances and shortfalls

I rolled an old retirement account into a rollover individual retirement account (IRA), but then discovered that IRA aggregation rules may make contributing to a backdoor Roth IRA difficult going forward. How does one affect the other?

The IRA aggregation rule was created to limit the ability of taxpayers to use non-deductible IRAs as a tax shelter. A non-deductible IRA is often used when a high-income earner wants to save in an IRA, but they earn too much to contribute directly to a Roth IRA or qualify for the tax deduction of a traditional IRA. As a result, their only option is to contribute to the traditional IRA and not take the tax deduction, which effectively makes it a non-deductible IRA. Once in the non-deductible IRA, many physicians choose to convert the money to a Roth IRA-a process often referred to as a “backdoor Roth IRA.”

In an effort to prohibit individuals from “cherry picking” distributions from their non-deductible IRAs and considering them as taxable or a return of principal, the IRS mandated that all IRAs be aggregated when determining the tax consequences of making a distribution.

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As an example, assume you rolled $50,000 from a previous retirement account into an IRA rollover. Now you want to take advantage of a backdoor Roth IRA and contribute $5,500 into a non-deductible IRA with the intention of converting it to a Roth. When the conversion takes place, the IRS considers it a distribution from the non-deductible IRA, and the IRA aggregation rules must be applied. To determine what amount is return of principal versus what amount is taxable, you must divide the converted amount by the aggregate value of all non-Roth IRA accounts.

In this example, you would divide $5,500 by $55,500 ($50,000 + $5,500), which is approximately .0991. This means that $545.05 ($5,500 x .0991) is considered return of principal and can be transferred into the Roth IRA tax free; the remaining $4,954.95 ($5,500 – $545.05) is subject to taxes. The taxable amount is taxed at your top marginal tax rate. If we assume a top marginal tax rate of 35%, then the tax due on the transfer is $1,734.23 ($4,954.95 x 35%).

There are two different ways you can handle the tax payment. You can net it out of the total amount transferred into the Roth account. In our example, that would result in $3,220.72 ($4,954.95 – $1,734.23) being transferred into the Roth account after the taxes had been paid. The other option is to transfer the full $4,954.95 into the Roth account and then pay the taxes due when it comes time to file your taxes.

"Paying taxes as a result of the IRA aggregation rule isn’t all negative."

Paying taxes as a result of the IRA aggregation rule isn’t all negative. By paying taxes when the conversion and transfer occurs, the next time you go through this conversion process, you get to reduce the pre-tax balance by the amount you paid in taxes the year before.

Using our previous example, next time the conversion takes place, instead of dividing $5,500 by $55,500, you would divide it by $53,765.77 ($55,500 – $1,734.23). Investment gains and losses in the pre-tax account may result in different amounts prior to subtracting the $1,734.23, but for simplification purposes, this example will work. Each year taxes are paid on the conversion, it further adds to the basis and reduces the amount used to determine how much passes to the Roth RIA tax free versus amounts that are taxable.

401(k) with a previous employer: What are your options?

Overall, IRA aggregation rules can be very complicated and may apply to many other scenarios related to distributions from your IRAs. We recommend speaking with your financial adviser about the impact of opening different types of IRAs and how it may affect distributions in the future.

What types of accounts are subject to the IRA aggregation rules?

The IRS requires you to use the IRA aggregation rules to compute the pro-rata taxable and non-taxable amount when a distribution is made from any non-Roth IRA. This includes traditional IRAs, non-deductible IRAs, SEP IRAs, and SIMPLE IRAs. Notably, the aggregation rule is only for IRA accounts. Employer retirement plans such as 401(k)s, 403(b)s, or profit-sharing plans are not subject to these rules. For this reason, some may consider rolling existing IRA accounts into employer-sponsored plans to minimize possible tax impact.

Additionally, inherited IRAs are also exempt. Finally, an individual’s IRAs are never aggregated with a spouse’s. Each person’s aggregation circumstances are calculated separately.

Mr. Witz is educational program director at MEDIQUS Asset Advisors, Inc. in Chicago. He welcome readers’ questions and can be reached at 800-883-8555 or 

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice.

The rule must be applied when making a distribution from non-Roth IRA.

How to make sense of the IRA aggregation rule

On Nov. 23, 2018, the Centers for Medicare & Medicaid Services (CMS) published its final rule revising payment policies under the Medicare Physician Fee Schedule. Most of the proposed changes to the Quality Payment Program outlined in the proposed rule were finalized (see, “How proposed rule will affect Quality Payment Program,” September 2018). In this article, I will summarize those changes to the Quality Payment Program that may impact your urology practice.

 The low-volume thresholds for Merit-based Incentive Payment System (MIPS) eligibility were finalized as proposed. Individuals or groups that do not exceed $90,000 in Medicare charges, 200 unique beneficiaries, or 200 professional services will be automatically excluded from MIPS. Clinicians who exceed all three of these thresholds will automatically participate in MIPS, and those who exceed one or two criteria can opt into the program.

Urology practices that employ physician assistants or nurse practitioners-who may not exceed these low-volume thresholds as individuals-may wish to participate as a group, especially in the early years of a program when positive payment adjustments are more achievable.

The MIPS composite score required to avoid a negative adjustment was finalized at 30 points, and the threshold for participating in the “exceptional performance” pool of $500 was changed from 70 points to 75 points for the 2019 performance year. By statute, the maximum payment adjustment earned by performance during 2019 (applied in 2021) is +/–7%.

The final rule did not include any estimates of impact by specialty using these new thresholds, but in aggregate CMS projects that 798,000 eligible clinicians will participate in MIPS in 2019 (up from 604,000 in 2018), and $390 million in negative adjustments will be redistributed to MIPS clinicians who have a positive performance in 2019 (up from an estimated $118 million in 2018). The actual impact by MIPS composite score will not be known until a scaling factor is applied for the payment year, as required by law. Urologists should understand that the bar for performance will continue to rise and strive to achieve maximum performance to participate.

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A number of changes to the Quality category were finalized in the rule. As proposed, the 2019 weight for Quality will be 45%, and groups of 15 or fewer physicians can submit some quality measures via Part B claims whether they submit as individuals or as a group. Those same “small groups” can qualify for six bonus points added to the numerator of the Quality performance category if they submit data on at least one quality measure, a more generous bonus than originally proposed.

Also, eligible clinicians can submit quality measures via multiple different collection types-a change from previous years. The urology specialty measure set remains largely unchanged from 2018; proposed changes to add a BPH outcome measure and remove an incontinence measure were not finalized.

Urologists continue to have a limited number of outcome measures available, and MIPS requires that at least one outcome measure be reported. The selection of quality measures continues to be largely determined by which EHR and/or registry is used for MIPS reporting. Practices should know which measures they can choose from and have some mechanism in place to measure performance in real time and improve.

Cost, Improvement Activities, Promoting Interoperability categories

 Proposed changes to the Cost category were finalized, and the category will have 15% weight in the 2019 performance year. New inpatient and procedure episode measures were finalized, and none impact urology in 2019. As reported earlier, urologists will probably be impacted in 2020 with an episode measure for kidney stones. It is not too early to begin thinking about controlling costs that are under your control, as performance in this area will eventually have major impact on the MIPS score.

CMS data breaks down industry payments to urologists

This category (15% weight, 90-day reporting period) contains no significant proposed changes to the inventory of activities for the specialty of urology, and the activity weights (high, medium) and scores remain the same. However, the bonus for using certified EHR technology associated with some activities has been eliminated. This category continues to be easy for urologists.

 The most significant changes to MIPS were finalized in the Promoting Interoperability category. All scoring will be based on performance, and the measures have been consolidated into four objectives. Performance in this category will be optimized by maximizing e-prescribing, implementing electronic prescribing of controlled substances, making sure all patients are offered registration on a patient portal, and understanding the sending and receiving of care summaries. Practices should review these changes with their EHR vendor and monitor clinician performance in this category carefully. Finally, urologists will need to use 2015 EHR certified technology in order to achieve points in the Promoting Interoperability category-check with your vendor to be sure you are, or soon will be, upgraded.

Bottom line: The Quality Payment Program and MIPS continue to evolve, and urologists continue to have an opportunity to achieve positive payment adjustments. Future years should bring more urology-specific measures.

A limited number of outcome measures available to urologists.

What 2019 MIPS changes mean for your practice

As the new Congress, with the House of Representatives now controlled by Democrats, opens up shop this month, physicians-urologists included-will be looking for action on several key initiatives important to their practices and patients.

But the action doesn’t stop on Capitol Hill as the regulatory agencies, including the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), are in the midst of making important decisions that could have lasting impact on medicine and physicians’ practices.

On Capitol Hill, urology interests continue their fight for patient access to, and Medicare coverage of, PSA screening. That effort has led to a drive to reform the U.S. Preventive Services Task Force, whose 2012 recommendations resulted in a sharp decline in screening rates, according to one study 

Thus, the major urology organizations continue to seek enactment of legislation that would reform the USPSTF, giving specialists increased influence on task force recommendations. Chief sponsor of that legislation was Rep. Marsha Blackburn (R-TN), who was elected to the Senate in November.

“We’re now searching for a new sponsor in the House of Representatives,” said Mark Edney, MD, president of the American Association of Clinical Urologists (AACU). “We expect to have Sen. Blackburn’s continued support.”

USPSTF reform is also a priority for the AUA and LUGPA, both of which have lobbied extensively to win the bill’s passage.

Dr. Edney also said AACU strongly supports legislation introduced last February to require a study by the National Academy of Medicine on the use of genetic and genomic testing to improve health care.

The bill, if reintroduced in 2019, would direct HHS to enter into an agreement with the National Academy of Medicine to recommend how the federal government can support the use of genetic and genomic testing to allow for better delivery of precision medicine.

“AACU supports the use of tissue-based molecular testing as a component of risk stratification in prostate cancer treatment decision-making,” a statement by the AACU explains.

Another major congressional initiative for urology is reform of the Stark antikickback laws, enacted some 30 years ago, which Dr. Edney and others contend now stand in the way of the drive toward value-based care. Thus, there is strong support within urology for the Medicare Care Coordination Improvement Act, introduced last year by Sens. Rob Portman (R-OH) and Michael Bennet (D-CO), which would give the HHS secretary the option to allow exceptions for alternative payment models, an important component of value-based care.

“We’re seeking to update and reform the law to accurately reflect the health care delivery system as it is today,” said Deepak A. Kapoor, MD, chairman of health policy at LUGPA.

“Stark is a two-edged sword,” he contended. “It prevents you from distributing money based on volume or value of service. But, we are seeking to move to a value-based care model where we reward value over volume, and that is prohibited by Stark, the language of which is inconsistent with the shift to value-based care.”

‘Breathtaking changes’ in payment policies

On the regulatory front, Dr. Kapoor said that under the Trump administration, CMS is “making breathtaking changes,” particularly with respect to payment policies.

“Independent physician practices received a major victory with the the expansion of site neutrality, which substantially leveled the playing field and allows independent physicians to compete,” he said. However, he said LUGPA “will continue our emphasis on expanding the notion that it is inappropriate for the patient to pay more for the same service simply because of the address where the service is provided. Medicare should pay the same amount regardless of where the service is provided.”

Meanwhile, the AUA and other members of the Alliance of Specialty Medicine wrote to HHS to express concerns over its proposed 340B drug pricing plan.

HHS is seeking to create a new payment model called the International Pricing Index, under which certain drugs like cancer treatments administered by doctors would be reimbursed at rates similar to those charged by European countries instead of using the current rate structure.

Physician participation will be mandatory for physicians in randomly selected geographic areas with a goal of capturing half of Medicare’s Part B spending. The objective is to reduce Medicare spending on included drugs by 30%.

While LUGPA was not a signatory to the Alliance’s letter to HHS, Dr. Kapoor said the organization agrees with its intent.

“Rather than physicians acquiring Part B drugs directly, they will put mandatory for-profit middlemen in place who can control access to the drugs,” he said.

“They are going to institute pricing models that could devastate the development of new drugs,” he warned.

The Alliance, in its letter, objected to participation in the demonstration program being mandatory and expressed strong concerns about the use of middleman-brokers from whom physicians will obtain the drugs.

“They are incentivized not to use the most appropriate therapy, but the cheaper therapy,” Dr. Kapoor warned. “You need to have both sides of the equation. You can’t just be focused on cost. You also need to focus on the needs of the patient. This policy as written could be extremely disruptive. We are going to be working closely with other stakeholders to make sure CMS hears these concerns.”

Organized urology has varied agenda for 2019

Pretreatment for 14 days with tolterodine (Detrol) and Tamsulosin (Flomax) did not appear to relieve ureteral stent symptoms better than tamsulosin alone as measured by the validatedUreteral Stent Symptom Questionnaire (USSQ), say the authors of a recent study.

Stent symptoms are a significant problem to patients undergoing endoscopic stone surgery. Yet, the optimal medical therapy to address this issue has yet to be defined, according to the authors.

The researchers were disappointed with their findings and report that this further validates the principle that this class of medications has a limited clinical impact on patients with ureteral stent symptoms. The team of investigators concluded that other alternatives should be pursued.

“We are potentially exposing patients to some degree of side effects and costs,” said study investigator John Roger Bell, MD, assistant professor of urology at the University of Kentucky, Lexington.

The authors previously looked at the use of tolterodine to relieve ureteral stent symptoms in a randomized control trial, but the findings were disappointing and showed no significant benefit 

 For this current investigation, which was presented at the 2018 AUA annual meeting in San Francisco, the authors theorized that pretreatment with tolterodine could improve outcomes by allowing tolterodine to attain a steady state concentration prior to the insertion of the ureteral stent.

They conducted a double blind, placebo-controlled trial in which patients were randomized to undergoing ureteroscopy and receive tamsulosin plus tolterodine (combination therapy) or to tamsulosin plus placebo (monotherapy). The medical therapies were given 14 days prior to stent insertion and continued for 7 days post operatively.

The study included patients undergoing uncomplicated ureteroscopy for urinary stone disease, and individuals were excluded if they were unable to take anticholinergics. In addition, patients were excluded if they already were taking anticholinergic medications for lower urinary tract symptoms.

The primary outcome for the study was the USSQ score. The USSQ was assessed at time of enrollment, day of surgery, day after surgery, last day of medication or day of stent removal, and day after stent removal. The authors added domain scores for each patient and compared the two groups.

“Until we come up with a more targeted or better therapy, this is what people are using,” said Dr. Bell. “Yet, it may be providing little benefit.”

The authors were hoping to enroll 100 patients and have data on at least 75. However, to date only 74 patients were enrolled and 43 were included in the final analysis. Dr. Bell said he does not expect that the trends would have changed significantly if there were a larger cohort.

“When evaluating these patients’ symptoms based on the USSQ questionnaire, we found no difference between the groups,” Dr. Bell said in an interview with 

. “Currently, we have the trial on hold.”

He said unfortunately at this time, there are no proven effective medical therapies to provide patients who are undergoing endoscopic stone surgery. Dr. Bell said it is just matter of tailoring treatment to each patient based on their individual symptoms.

“We need to keep evaluating why patients have stent symptoms. We don’t really have a good answer for that yet,” said Dr. Bell.

Dr. Bell is a consultant for Boston Scientific and a speaker for Cook Medical.

Pretreatment for 14 days with tolterodine (Detrol) and Tamsulosin (Flomax) did not appear to relieve ureteral stent symptoms better than tamsulosin alone as measured by the validated Ureteral Stent Symptom Questionnaire, say the authors of a recent study.