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Medicare proposed rule outlines significant changes


"If the rule changes proposed by Medicare for 2019 are passed, they may very well change the way you practice," write Ray Painter, MD, and Mark Painter.





Every year, Medicare is required to publish a proposed set of rule changes for the next year. If the rule changes proposed by Medicare for 2019 are passed, they may very well change the way you practice. While this rule is not final, the proposed rule set is often very close to the final rule, which will be published in early November. 

In this article, we will summarize a few of the most important proposed changes. You can download the entire document at bit.ly/2019proposedrule. We encourage urologists to consider commenting on the proposed rule. (See “How to comment on proposed rule.")

As we see the reaction and get closer to deciphering the final rule to be implemented, we will be providing more information on its impact and how to implement these changes in your practice.

Key changes to be discussed in this article include:

  • documentation guidelines and changes to payment for evaluation/management (E/M) services
  • add-on G codes for certain urologic E/M services
  • payment for some phone calls or other non-face-to-face inpatient encounters
  • cuts in payment for the –25 modifier
  • changes in documentation for time-based E/M services
  • changes in payment for some Part B drugs
  • payment for cystoscopies.

Next: E/M documentation guidelines and payment for E/M services

E/M documentation guidelines and payment for E/M services

The proposed changes remind us of the old saying, “Be careful what you wish for; you just might get it.” If adopted, you will no longer have to record detailed information that is not pertinent to your office and outpatient E/M services (99201-99215), nor will you have to document physical observations and perform physical exams that are not medically necessary. Copying previous encounters should be a thing of the past. How often have you wished you did not have to spend the time documenting information that was not medically necessary?

The proposed changes to documentation requirements include:

  • simplified documentation for all outpatient visits
  • allowing practitioners to choose medical decision-making (MDM), time, or keep using the 1995 or 1997 guidelines, as a basis to determine the appropriate level of E/M visit
  • allow any E/M visit to be charged based on time
  • chief complaintand history of present illness can be entered by staff or patient and reviewed by practitioner, but does not have to be reentered.

The proposed changes to payment for outpatient E/M services include:

  • pay a single rate for levels 2 through 5 of office and other outpatient new and established patient E/M services
  • add-on G codes for certain E/M visits, including some urologic visits.

The details of the proposals provide us with some pleasant surprises. First and foremost, the documentation requirements have been reduced even if you choose to document based on the ’95 and ’97 guidelines. For the purposes of payment for an office/outpatient E/M visit, practitioners would only need to meet documentation requirements currently associated with a level 2 visit for history, exam, and/or MDM. For example, to qualify for the established patient E/M visit, one would have to document only three elements on the history of present illness, no review of systems or past family social history, and document no physical exam, for a problem not requiring active treatment.

Even though the requirements have been reduced, they make it clear that their expectation is that practitioners would continue to perform and document E/M visits as medically necessary for the patient to ensure quality and continuity of care. What a novel idea: Document only what you think is medically necessary for the patient.

The CPT codes would not be changed and the current codes would still be reported as supported by the now-optional method chosen by the practice: either MDM, time, or under the current guidelines with some modification.

One proposed option for billing based on time uses a blend of the times currently required for levels 2 through 5. For an established patient, the required time would be 31 minutes. Then apply the rules established by CPT in which time documented for each code is an average rather than threshold time. The documented time required to bill the established patient code would be 16 minutes.

Prolonged E/M service add-on code reporting would be changed to require specific notation of the prolonged time as well as the typical or base time for the E/M code reported. (This will require more input and discussion.)

The single payment for all E/M services (levels 2-5) would be $135 for a new patient and $93 for an established patient. These are considered to be a weighted average of the four codes over the past 5 years. Tables 1 and 2 were included in the proposed rule illustrating the payment plan.

Physician Reimbursement Services projected a blended payment rate using Medicare percentages for urology and current 2018 prices reported to Medicare to approximate a blended level 2 to 5 fee for new patients and established patients. This calculation is a rough estimate by summing the product of the current fee and percentage for each category. Using this formula, the new patient fee would be $143.89 and the established patient fee would be $84.82. 

To project an overall impact for urology, we used data from IntrinsiQ’s InfoDive data platform (used by PRS and a number of urology practices across the country) to estimate the number of visits for each category billed in a 12-month period.

Using this method, an average urologist would see an increase of $18,891.71 in a year under the new payment system. This projection does not take into account the lost revenue that would result from the decrease in payments for E/M codes billed with modifier –25 addressed below. Nor does the number take into account the increase that would result from using the G code for standalone E/M codes addressed below. CMS projected less than a 3% increase in overall payments to urology.

We continue to search for more data to refine our projections. Additionally, we will need some clarification on appropriate use of the G code in the final rules to provide a more accurate projection. We anticipate revising these projections in our December column.

Of course, the impact on your practice income will require analysis of your current billing patterns. Please feel free to contact PRS for assistance in calculating projections for your practice; we hope that the explanation provided here can assist you in running these projections on your own.

Next: New E/M ‘add-on’ G codesNew E/M ‘add-on’ G codes

The Centers for Medicare & Medicaid Services is proposing to create two new HCPCS codes that might be used by urologists:

GPC1X. Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to an established patient evaluation and management visit)

GCG0X. Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit).

GPC1X is proposed to be used only with established patient visits that include primary care services. This code is targeted to the specialties providing true primary care, such as family practice or pediatrics. CMS, however, does acknowledge that some specialties do provide primary care services to some of their patients. While urology is not specifically mentioned in the proposed rule, an argument could be made that some patients rely on urologists for their primary care while not under the care of other providers, and some urology practices have added primary care to their service mix through either urologists or advanced-practice providers employed by the practice. We will keep an eye on the final rules surrounding the use of this code.

GCG0X will be an add-on code to be charged with the appropriate standalone E/M code for visits. The code will pay about $14 in addition to the new common payment. The final rules governing when this code can be used will be very important as we look at the impact of this change.


50% pay cut for E/M services with –25 modifier

CMS is proposing to apply the surgical multiple payment discount rule to any E/M service provided on the same day as a procedure. Therefore, the agency has proposed cutting the payment for the lower valued code-either the E/M code or the procedure code reported-by 50%.

This is a rule change that deserves many comments by urologists explaining that an E/M service that results in performing a cystoscopy on the same day constitutes two services with minimum overlap in time and resources.

CMS is required to make changes in a budget-neutral manner and has estimated that this change will save CMS 6.7 million relative value units (RVUs) per year (roughly $239 million). The RVUs/money saved by reducing the payment for encounters in which a –25 modifier is used is targeted to fund the new Evaluations and Management Specialty Add-on G code GCG0X.

Next: Virtual check-in codeVirtual check-in code

CMS is proposing to add coverage for a virtual check-in visit patterned after current telephone codes included in CPT. This service would be billable when a physician or other qualified health care professional has a brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit. The code is GVCI1 (Brief communication technology-based service, eg, virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion). The code description provides significant guidance as to when the service can be reported.

We can see a number of applications for this code in urology. CMS is seeking comment on appropriate parameters to prevent overuse and abuse of this service.


52000 practice expense adjustment

CMS has acknowledged that essential sterilization equipment was left out of the practice expense calculation in 2017. The equipment and the associated time for the process will be added back into the practice expense value. This should provide at least a little gain in the value of code 52000 for 2019.



We have only provided a high-level review of a portion of the proposed rule. We encourage you to also read Dr. Robert Dowling’s “Practice Matters” column in an upcoming edition of Urology Times for more information on the proposed rule and its impact on urology. We will continue to add information in future articles and encourage you to consider ways to support or oppose these proposals. Based on the tone of the proposed rule, it appears that CMS is listening. Last but not least, we anticipate significant resistance to the simplification from medical specialties. The demands of numerous internal medicine subspecialties for more pay for non-surgical patients is the reason we have the current complicated system. Prior to 1992, there were only three levels of outpatient visits and only medically necessary documentation was required.

Next: How to comment on proposed rule

How to comment on proposed rule

We encourage urologists to consider commenting on the proposed rule via one of the below methods:

  • direct response to CMS; this can be done electronically by going to www.regulations.gov and following the “Submit a comment” instructions or via mail to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, P.O. Box 8016, Baltimore, MD 21244-8016
  • write or call the AUA, AACU, or LUGPA (contact should be directed to health policy departments)
  • send your thoughts to Physician Reimbursement Services (via email to markp@prsdata.com or rayp@prsdata.com).

Comments must be received by CMS no later than 5 p.m. on Sept. 10, 2018, so please send your comments in a timely manner.


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.






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