On July 13, the Centers for Medicare & Medicaid Services (CMS) released the Calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule and accompanying fact sheet. The AUA staff will be reviewing the provisions of the rule and preparing comments, which are due September 11.

2024 Conversion Factor

The conversion factor for 2024 is set to decrease by approximately 3.36% from $33.8872 to $32.7476. The proposed conversion factor decrease is the result of a statutory 0% update scheduled for the physician fee schedule in 2024, a negative 2.17% RVU budget neutrality adjustment, and the expiration of the funding patch Congress passed at the end of 2022 through the Consolidated Appropriations Act of 2023, that partially mitigated a cut to the 2023 conversion factor.

Impact to the Specialty of Urology

Table 104, CY 2024 PFS Estimated Impact on Total Allowed Charges by Specialty outlines the changes to payments for specialties and shows that urology is projected to see an increase of 1% in overall Medicare payments. Note that the impact to group practices and individual physicians will vary based on practice type, mix of patients and the types of services provided to those patients.  

CMS Accepted RUC Recommendations for New CPT® Codes

The AUA was instrumental in valuing new and revised CPT codes, through the AMA RUC survey process, used to report services for cystourethroscopy and bladder dysfunction. CMS proposes to accept the RUC-recommended work RVU of 3.10 for a new CPT code for 5X000 (Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed). The code will be available for use January 1, 2024.

Additionally, CMS proposes to accept the RUC recommended work RVUs for neurostimulator services associated with bladder dysfunction. Those services are described by CPT codes 64590 (Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver) and 64595 (Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array) and will have work values of 5.10 for 64590 and 3.79 for 65495.  

Telehealth

CMS continues to support the use of telehealth, and has proposed changes to allow for greater Medicare beneficiary access to these services. The agency proposes a refined process to review requests to add services to the Medicare Telehealth Services List on a temporary or permanent basis. 

Additionally, CMS proposes to implement several telehealth-related provisions of the Consolidated Appropriations Act of 2023, including the temporary expansion of the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home, and the continued coverage and payment of telehealth services included on the Medicare Telehealth Services List until December 31, 2024.

CMS proposes that telehealth services provided to people in their homes be paid at the non-facility PFS rate. This proposal aligns with telehealth flexibilities that were included in the Consolidated Appropriations Act of 2023.

The agency has also proposed to allow direct supervision through real-time audio and video interactive communications through December 31, 2024.

Rebasing the Medicare Economic Index

In the CY 2023 rule, CMS finalized methodological and data source changes to the MEI, which would have had significant impacts on MPFS payments. However, CMS proposes to delay the implementation of those updated cost weights since the American Medical Association is launching a survey to collect on representative data on physician practice expenses.

Split/Shared Services

CMS proposes to delay, yet again, the implementation of the definition of the “substantive portion” as more than half of the total time through at least December 31, 2024. This revised definition provides that the practitioner who spends more than half the time with the patient would bill for the visit. Stakeholders have expressed concern that this is inconsistent with how other evaluation and management (E/M) services are billed. In this rule, the agency has proposed to allow the current definition of substantive portion to remain in effect for CY 2024, which allows for the use of either one of the three components—history, exam or medical-decision making—or more than half of the total time spent to determine the provider that will bill for the visit.

Evaluation and Management (E/M) Services

CMS is implementing a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211, which will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care of complex patients.  This code will generally be applicable for outpatient visits as an additional payment that recognizes the additional resources required to treat a patient’s single, serious, or complex chronic condition. 

CMS had originally finalized this policy in the CY 2021 MPFS final rule. However, Congress intervened and prohibited the policy from being implemented before January 1, 2024.  CMS proposes refinements to the policy, specifically that the add-on code could not be billed with a modifier that denotes an office and outpatient E/M visit that is unbundled from another service. The agency also modified the utilization estimates for the code, which lowered the overall impact on the payment system. In a budget neutral payment system such as the MPFS, changes in payment for one code may lead to decreases in payment for other codes. By lowering the usage estimation for G2211, CMS decreased the overall impact to other services.

Requiring Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs to Provide Refunds With Respect to Discarded Amounts

CMS finalized policy to require the reporting of the JW modifier to report discarded amounts of single-dose containers and the JZ modifier for such drugs with no discarded amounts in the CY 2023 MPFS final rule. This policy was mandated by §90004 of the Infrastructure Act. This year the agency proposes related policies, including timelines to provided the reports to manufacturers; the method of calculating refunds for discarded amounts from lagged claims data; how to calculate refunds when there are multiple manufacturers for a refundable drug; increased applicable percentages for certain drugs with unique circumstances; and an application process for manufacturers to request an increased applicable percentage for a drug with unique circumstances.

Provisions from the Inflation Reduction Act Relating to Part B Drugs and Biologicals

In this proposed rule, CMS proposes policies to limit beneficiaries’ out-of-pocket costs for certain Part B drugs in accordance with the Inflation Reduction Act of 2022. Specifically, beneficiary coinsurance will be based on the inflation-adjusted payment amount if the Medicare payment amount for the calendar quarter exceeds the inflation-adjusted payment amount for Part B rebatable drugs.

Quality Payment Program

CMS proposes changes to the Quality Payment Program (QPP) in this proposed rule and requests information on a range of topics, including the future of the program and Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPS), alignment between the QPP and the Medicare Shared Savings Program, and publicly displaying information on Care Compare.