On Friday, November 1, the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 Medicare Physician Fee Schedule final rule and fact sheet. Below is a summary of some of the major provisions that will affect urologists.

Conversion Factor

The conversion factor for 2025 is set to decrease by approximately 2.83% from $33.2875 to $32.3465. The cut is driven by the expiration of the conversion factor increase that Congress passed in March, coupled with a 0% baseline update. Since CMS does not have statutory authority to eliminate or reduce this cut, the AUA has endorsed the Medicare Patient Access and Practice Stabilization Act of 2024, which would eliminate the entire conversion factor cut and provide an update equal to half of the Medicare Economic Index for 2025.  Besides supporting this legislative fix for 2025, the AUA continues to work diligently to advocate for Congress to enact permanent policy changes to the conversion factor update, and to ensure that the conversion factor reflects the costs of providing care to Medicare beneficiaries.

Impact to the Specialty of Urology

CMS estimates the policies in the final rule will result in no change to the total Medicare allowed charges for urology. This is a change from the proposed rule as the specialty of urology was expected to see a decrease of 1% in total Medicare allowed charges. 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 reflect the conversion factor decrease.

CMS Finalizes Relative Value Units for Prostate Procedures

CMS finalized the AMA RUC recommended values for the following new CPT codes for ablation of prostate tissue (51721, 55881, and 55882) and bladder neck and prostate procedures (53865 and 53866). However, for the services associated with removal or destruction of intra-abdominal tumors (49186-49190), the agency finalized lower values than recommended by the RUC for two of the procedures. The AUA is pleased that CMS accepted the RUC recommended work values for the prostate services, and we will continue to work with the agency to support the appropriate valuation of urologic services.

Additionally, for services associated with CPT codes 53865 and 53866 (bladder neck and prostate procedures), CMS increased the supply price input for the iTind device used in these procedures. During the comment period the agency received additional invoices for the device. CMS used the invoices to create an average price based on the additional invoices submitted by the commenter coupled with invoices submitted the RUC. Therefore, the new supply price for iTind is $2,972.50, a $277.50 increase from the proposed price of $2,695.00.

Appendix A lists the new CPT codes and final descriptors along with the RUC recommended work values and the CMS final work values.

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

CMS finalized 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. This is in addition to current policy which allows for the add-on code to be billed with O/O E/M visits when the practitioner has or intends to form a longitudinal relationship with the patient.

Global Surgical Package Changes Includes a New HCPCS Add-on Code

CMS finalized 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.

Differing slightly from the proposed policies which would have broadened the use modifiers -54 (surgical care only), -55 (post-operative management only), and -56 (preoperative management only). CMS has finalized the use of modifier -54 (surgical care only) and will require that it be used on all “90-day global surgical packages in any case when a practitioner plans to furnish only the surgical procedure portion of the global package (including both formal and other transfers of care).” For modifiers -55 and -56, there are no policy changes, and those modifiers are to be used only when there is a documented formal transfer of care.

CMS finalized HCPCS code G0559, an add-on code used to report services for post-operative care provided to a Medicare beneficiary by a practitioner that did NOT perform the surgical procedure. The code was created by the agency to capture the time and resources needed in these instances. The code may only be coupled with an office E/M service for new or established patients. Also, G0559 is only billable once during the 90-day global period. The final work RVU is 0.16. The complete description, along with the required elements of the new code may be found on page 740 of the display copy of the final 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 will not make separate payment for the new telehealth E/M codes. CMS continues to believe the telehealth E/M CPT codes are duplicative of the current set of E/M CPT codes. Medicare payment for telehealth services will continue as is, using place of service indicators and modifiers.

CMS finalized the definition of an interactive telecommunications system to include two-way, real-time audio-only. Beginning January 1, 2025, interactive telecommunications system may include 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 beneficiary may not be capable or may not consent to the use of video technology, therefore real-time audio only would be an acceptable means to deliver the telehealth service.

Additionally, CMS finalized the 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 finalized policy that allows teaching physicians to supervise residents virtually in teaching settings. This policy will run through December 31, 2025. 

Appendix A: New CPT Codes, RUC Proposed and CMS Final Work RVUs