The Centers for Medicare & Medicaid Release CY 2025 Proposed Rule for the Medicare Physician Fee Schedule

On Wednesday, July 10, the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 Medicare Physician Fee Schedule proposed rule and fact sheet.  The following is a high-level summary of the policies that will affect AUA members. AUA will be reviewing the proposed rule and submitting comments in advance of the September 9 deadline.

• CY 2025 MPFS Impacts on Urology Codes Compared with CY 2024 Rates (Facility and Non-Facility Rates)
• CY 2025 MPFS Impacts on Evaluation & Management Codes Compared with CY 2024 Rates (Facility and Non-Facility Rates)

Conversion Factor

The conversion factor for 2025 is set to decrease by approximately 2.80% from $33.2875 to $32.3562. The cut is primarily driven by the expiration of the conversion factor increase that Congress passed in March.

Impact to the Specialty of Urology

CMS estimates that, if implemented, the policies in the rule will result in a decrease of 1% in total Medicare charges for urology, primarily due to changes in the practice expense values for some services. Note that the impact on group practices and individual physicians varies based on practice type, payer type, mix of patients and the types of services provided to those patients. Also, this estimated impact does not factor in the conversion factor decrease.

CMS Accepted RUC Recommendations for New CPT® Codes

The AUA continues to serve our members by participating in the AMA RUC process and advocating for relative value units (RVUs) that reflect the work of urologists. By participating in the survey process, the society was able to advocate for work and practice expense values for new CPT codes created to report ablation of prostate tissue services and, bladder neck and prostate services. Additionally, AUA collaborated with other specialties to develop RVUs for removal or destruction of intra-abdominal tumors.

CMS has proposed to accept the AMA RUC recommended values for the following new CPT codes for ablation of prostate tissue (5X006, 5X007, 5X008) and bladder neck and prostate procedures (5XX05 and 5XX06). However, for the services associated with removal or destruction of intra-abdominal tumors (4X015-4X019), the agency has proposed lower values for two of the procedures. Note that none of these are final code numbers. The complete code number will be provided when the final rule is released in early November.

Appendix A lists the new codes with RUC recommended values and CMS proposed values for services performed by urologists.

Proposed Refinement for Use of G2211 - Complex Care Add-on Code

CMS is proposing to allow payment of the Office/Outpatient (O/O) Evaluation and Management (E/M) visit complexity add-on code G2211 when the O/O E/M base code is reported by the same provider on the same day as an annual wellness visit, vaccine administration, or any Medicare Part B preventive service that is furnished in the office or outpatient setting.

Global Surgical Package Values Back in the Spotlight

After years of studying the concept of the global surgical package and the associated payments, the agency has proposed two changes that will allow the agency to collect information on the resources involved in providing global surgical services and the associated follow-up visits.

First, CMS has proposed to “broaden the applicability of the transfer of care modifiers” and require that practitioners use the existing modifiers for all 90-day global surgical procedures when a practitioner other than the one performing the procedure is expected to provide the pre- and post- operative portions of the service. The modifiers are 54 (surgical care only), 55 (post-operative management only), and 56 (preoperative management only).

Additionally, CMS has proposed a new HCPCS code, GPOC1 that is to be used when a practitioner provides post-operative care to a Medicare beneficiary when the practitioner did NOT perform the surgical procedure. The code was created by the agency to capture the resources provided to a surgical patient post-operatively, despite the absence of a formal transfer of care. The code may only be reported with an office E/M service for new or established patients. Also, GPOC1 may only be billed once during the 90-day global period because the agency “believes the practitioner would only have additional resources costs up the first visit following the procedure.” The proposed work RVU is 0.16. The complete description of the new code may be found on page 353 of the display copy of the proposed rule.

Telehealth Updates

After extensive efforts by the AMA CPT Editorial Panel to create and the AMA RUC to value E/M codes specifically for the provision of telehealth visits, the agency has proposed NOT to value and pay for the new telehealth E/M codes. The agency stated that the telehealth E/M codes are duplicative of the current set of E/M codes, and therefore, Medicare will continue to pay for telehealth services using place of service indicators and modifiers.

CMS will modify the definition of an interactive telecommunications system. Beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time audio-only communication technology or any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the Medicare may not be capable or may not consent to the use of video technology.

Additionally, CMS is proposing to permanently adopt a definition of direct supervision for certain services that allows the physician or supervising practitioner to provide supervision through real-time audio and visual interactive telecommunications. The agency is also proposing to continue the policy that allows teaching physicians to have a virtual presence for services provided by residents in teaching settings through December 31, 2025.