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

November 25, 2020
Jonathan Rubenstein, MD

,
Mark Painter

Mark Painter is CEO of PRS Urology SC in Denver.

Evaluation/management changes should benefit providers and patients.

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.

Normally, our Urology Times® 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.

Telehealth

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.

E/M changes

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.

Conclusion

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.