On November 1st, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for CY 2023 (CMS-1770-F).  This rule updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP).  A pre-publication version of the rule can be found here. A press release and fact sheet are also available. Impacts of the MPFS on urology codes and E/M codes are linked below.

• CY 2022 MPFS Impacts on Urology Codes Compared with CY 2021 Rates (Facility and Non-Facility Rates)
• CY 2022 MPFS Impacts on Evaluation & Management Codes Compared with CY 2021 Rates (Facility and Non-Facility Rates)

Conversion Factor: The CY 2023 Medicare conversion factor (CF) is set at $33.06, a decrease of 4.5% from the 2022 CF of $34.61. The decrease is mainly the result of the expiration of a 3% increase funded by Congress through 2022.  The other 1.6% decrease is the result of budget neutrality requirements due to changes in the inpatient E/M codes and hospital observation, emergency department, nursing facility, and home or residence services. The AUA has been lobbying Congress to avert this payment cut, as there is nothing the agency can do without an act of Congress.

Specialty Level Impact: Table 128 of the final rule outlines the financial impact of finalized policy. Urology is projected to see a decrease of 1% in Medicare payments. The impact amounts in Table 128 only includes changes to rate setting and changes to RVUs under the budget neutral system, not the impact of the conversion factor decrease. Note that the impact to individual or group practices varies based on practice type and mix of patients and services provides to those patients.

Code Level RVUs: In this rule, CMS accepted the Relative Value Scale Update Committee’s (RUC) recommended work and PE relative value units (RVUs) for laparoscopic simple prostatectomy procedures as reported by CPT codes 55821, 55831, 55866, and 55867. The AUA participated in the RUC survey for these codes and is pleased to see CMS finalized RUC recommended values.

However, regarding values for percutaneous nephrolithotomy (50080 and 50081), the AUA submitted comments objecting to CMS proposed RVUs, which were lower values than the RUC recommended values for these services. CMS rejected the arguments of commenters that the RVUs proposed by RUC were not appropriate. The agency noted that in general, when the time for a service decreases, then the work RVU should have a corresponding decrease. The agency did, however, add in additional RVUs (0.30) for the performance of a fluoroscopy as they believe this work was not accounted for in the proposed values.

Split/Shared Services: CMS continues to stand by its policy for billing split/shared services by time and has again reiterated that in 2024 a split/shared service is billed by the practitioner who provides a substantive portion of the visit using time as the determining factor. This policy applies only to services provided in the facility setting. However, CMS has delayed the implementation of this new policy for an additional year. The AUA advocated to the agency that using time rather than medical decision making to determine the substantive portion will undermine the agency’s efforts to move towards team-based care as physicians will be less likely to perform these visits.

Telehealth Services: The AUA advocated for CMS to add, on a permanent basis, telephone-only services (99441-99443) to the telehealth services list, however the agency has finalized its proposal to NOT add to the telehealth services list but will continue to pay for these services for 151 days after the PHE expires. At day 152 after the PHE ends the telephone-only E/M services will revert as unpayable and considered bundled under the MPFS.

Discarded/Wasted Drugs: In the proposed rule, CMS considered whether to use the authority granted by Congress to raise the applicable percentage of waste that triggers a refund for drugs with unique circumstances. Specifically, the agency considered drugs that must be reconstituted with hydrogel noting that a substantial amount adheres to the vial wall during preparation. The agency speculated 35 percent may be appropriate to account for the portion of the drug that adheres to the vial. The AUA commented that CMS should use its authority and finalize policy that raises the applicable percentage to 35 percent for wastage associated with drugs reconstituted with hydrogel. With this rule, CMS has finalized its proposal to allow for 35% wastage, and in this case, only one drug Jelmyto® (mitomycin for pyelocalyceal solution).

The AUA will publish a more thorough analysis, including final impact tables for commonly billed urologic codes, in the coming days as we continue to review the final rule. For questions or comments, please contact Bhavika Patel, Manager for Physician Payment and Reimbursement at bpatel@auanet.org.