Urology takes heavy hit in 2010 Medicare updates

December 1, 2009

Once again we face a Medicare payment update for the new year that raises a number of questions, the answers to which are not favorable to practicing urologists.

That being said, not all news is as bad as predicted. The overall impact on urology is a modest 3% drop this year as a result of practice expense and coding changes. The decrease will reach 10% after the 4-year phase-in of the practice expense changes, as was predicted by Physician Reimbursement Systems. This assumes that Congress will act again to delay or fix the impact of the sustainable growth rate (SGR) formula. If Congress fails to act, the SGR will result in a 21.2% decrease in the conversion factor and all fees, in addition to the decrease for urology as a result of coding and value changes.

Although everyone expects Congress to fix or delay the SGR, the problem is real and is currently tied to health care reform. Medicine will need to keep up the pressure on Congress for a "doc fix" if health care reform efforts continue at their current pace. With delay in passage of a reform measure and the current environment on Capitol Hill, every urology office will have to carefully consider what it wants to do in January.

Consultation codes invalid

As proposed by the Centers for Medicare & Medicaid Services, all consultation codes will no longer be valid for Medicare patients after Jan 1. The codes are still included in the Medicare fee schedule and will be in the American Medical Association's Current Procedural Terminology book, but the status of all consult codes has been changed to "I." This status means that the codes are not valid for Medicare purposes. If you report them on a claim, they will be denied.

The values have not been changed-only their status for Medicare purposes has. This translates into a change for your office as of Jan. 1, 2010, but at this point, only for Medicare and perhaps a few private carriers, dependent upon your contracts. Your office will have to monitor what other payers plan to do; this includes your managed care Medicare (Medicare Advantage) carriers, some of which may continue to pay for consultations.

For Medicare, you will no longer have the choice of reporting 99141-99145 for services rendered in the office or outpatient setting and will need to switch these services to either new patient codes (99201-99205) or established patient codes (99212-99215). In the hospital setting, your first encounter with the patient will be reported under an initial inpatient code (99221-99223); all other billable encounters are to be reported with subsequent hospital visit codes (99231-99233). Medicare is creating a modifier, to be reported by the admitting physician, which distinguishes the admitting physician from others seeing the patient during the inpatient stay.

CMS has reallocated the values for consultation codes to other evaluation and management visits in a budget-neutral manner. The result of the shift is an increase in work values for the remaining E&M codes that will replace the consultation code use and a small increase in work values for major (90-day global) procedures.