On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Medicare Physician Fee Schedule (MPFS) for Calendar Year 2025. This rule outlines the payment policies and rates for Part B medical services provided to Medicare beneficiaries under the MPFS for 2025 as well as provides updates to the Quality Payment Program. Within the final rule, there are responses provided by interested parties regarding the MPFS proposed rule, which was issued in July. Below are some key highlights and important updates for urologists and urology groups. Please note that this article, written in early December 2024, does not include any potential changes or actions by Congress that may occur after this date.

Conversion Factor for 2025

The conversion factor (CF) for 2025 is set to decrease once again, this time by 2.83%, from $33.2875 in 2024 to $32.3464. This reduction is mainly due to a 0% baseline update and the expiration of a onetime CF increase approved by Congress in March 2024 for Calendar Year 2024. This decrease in CF further strains practitioners and practices as reimbursement rates continue to lag behind rising costs and inflation. Combined with CMS’ estimate of a 3.6% increase in practice cost expenses for the coming year, this results in a total relative reduction of approximately 6.4% if Congress does not intervene.

Representative Greg Murphy, MD (R-NC-03), along with a bipartisan group of cosponsors, has introduced the Patient Access and Practice Stabilization Act (H.R. 10073), which aims to eliminate the 2.83% cut and provide partial relief from inflationary cost increases. It is crucial for members of Congress to understand how these cuts will adversely affect the ability of practitioners to continue serving Medicare patients. The AUA strongly encourages its members to contact their representatives and urge them to cosponsor the Patient Access and Practice Stabilization Act.

Supply Pack Pricing Update

The practice expense (PE) portion of the MPFS payment formula includes the cost of supplies, equipment, and clinical labor required to perform each service. It was observed that the cost of certain supply packs, such as those containing drapes and gowns, was higher than the sum of their individual components. Through the American Medical Association’s Relative Value Update Committee, it was determined that reimbursements for 3 supply packs commonly used in urologic procedures would be adjusted.

While the pack for cleaning and disinfecting an endoscope (SA042) was found to be undervalued and will see an increase from $19.43 to $31.29, 2 cystoscopy supply packs were found to be overvalued. The pack for cystoscopy drapes (SA045) will be reduced from $17.33 to $14.99, and the pack for cystoscopy visits (SA058) will drop significantly from $113.70 to $37.63. In response, the AUA submitted comments recommending a 4-year phase-in approach to these changes to help practices adjust to the financial impact. CMS agreed to this suggestion and will phase in both the reduction of the cystoscopy pack (SA058) and the increase for the endoscope cleaning pack (SA042) over a 4-year period (Table 1).

Table 1. Supply Pack Practice Expense Phase-In Payments per Calendar Year

Valuation of New Current Procedural Terminology Codes of Interest to Urology

There were 3 new current procedural terminology (CPT) code sets added for 2025 that are of most interest to urology: intra-abdominal tumor excision or destruction (CPT codes 49186, 49187, 49188, 49189, and 49190), bladder neck and prostate procedures (CPT codes 53865 and 53866), and MRI-monitored transurethral ultrasound ablation of prostate (CPT codes 51721, 55881, and 55882).

Five new CPT codes were added to the 2025 code set to describe the open excision or destruction of intra-abdominal, mesenteric, or retroperitoneal tumors. These codes should be reported when the procedure performed matches the description. Please note that these codes should not be used only for open procedure(s) and should not be reported for the laparoscopic excision or destruction of tumors. The code should be chosen based upon the total summed length of the tumor(s) excised or destroyed. These codes replace CPT codes 49203 to 49205, which will be deleted. In the final rule, CMS accepted and finalized the Relative Value Scale Update Committee (RUC)–recommended work values for 3 of the new codes (CPT codes 49186, 49187, and 49188). However, CMS did not accept the RUC-recommended work values for the remaining 2 codes (CPT codes 49189 and 49190; Table 2). Please note that these codes may be used by urologists and urologic oncologists for excision and destruction of retroperitoneal tumors even if these masses are within lymph nodes and should be differentiated from the performance of a retroperitoneal lymph node dissection, which should be used when not specifically removing masses.

Table 2. Relative Value Scale Update Committee–Recommended vs Centers for Medicare & Medicaid Services Final Work Relative Value Units for Excision or Destruction

In the final rule, CMS adopted the American Medical Association’s RUC-recommended values for 2 new CPT codes that describe services related to a temporary device designed to remodel the bladder neck and prostate for the treatment of lower urinary tract issues due to benign prostatic hyperplasia. This code set includes one for the placement of the device (CPT code 53865) and another for its removal without the use of cystoscopy (CPT code 53866). The iTind device (Olympus, Center Valley, Pennsylvania) is the currently available product that fits this definition. The final work relative value unit (RVU) of 3.10 was approved for CPT code 53865, representing the device placement, while CPT code 53866 for removal was assigned a work RVU of 1.48. In response to comments and invoices received during the rate-setting process, CMS increased the supply price input for the remodeling device, setting the final supply price at $2972.50, a $277.50 increase from the proposed price of $2695.00.

At the April 2023 CPT Editorial Panel meeting, the CPT Editorial Panel approved 3 new codes to describe services associated with MRI-monitored transurethral ultrasound ablation of the prostate (TULSA-PRO; Profound Medical, Rockville, Maryland). CMS finalized the RUC-recommended values for all 3 services with a work RVU of 4.05 for CPT code 51721 (insertion of the transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed), 9.80 for CPT code 55881 (ablation of prostate tissue, transurethral, using thermal ultrasound, including MRI guidance for, and monitoring of, tissue ablation), and 11.50 for CPT code 55882 (ablation of prostate tissue, transurethral, using thermal ultrasound, including MRI guidance for, and monitoring of, tissue ablation…with insertion of the transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed). The PE inputs were accepted without refinement.

Telehealth Services for Medicare

The CPT Editorial Panel created and RUC subsequently valued 17 new codes to describe services related to telemedicine Evaluation and Management (E/M) services. These include 16 codes (98000-98015) that cover 4 levels of telemedicine E/M visits: 4 for new patients via audiovisual telemedicine, 4 for established patients via audiovisual telemedicine, 4 for new patients via audio-only telemedicine, and 4 for established patients via audio-only telemedicine. Additionally, CPT code 98016 was created for brief communication technology-based services (eg, virtual check-ins) provided by a physician or qualified health care professional to an established patient. This service involves 5 to 10 minutes of medical discussion not originating from a related evaluation within the last 7 days nor leading to a subsequent evaluation or procedure within 24 hours or the next available appointment.

CMS finalized a policy stating there is no programmatic need to recognize or provide payment for 16 of these 17 newly established telemedicine E/M codes, opting only to recognize CPT code 98016. The other 16 codes were assigned a status indicator of “I,” indicating they are not separately recognized under Medicare and should be reported using existing office/outpatient E/M codes. CMS will also delete Healthcare Common Procedural Coding System code G2012, used for similar services, and starting January 1, 2025, providers must use CPT code 98016 to report virtual check-ins. Code 98016 will have a work RVU of 0.30, and CMS has finalized the RUC-recommended direct PE inputs. Additionally, telephone E/M service CPT codes 99441 to 99443 will be deleted and cannot be used starting January 1, 2025.

The current laws covering telehealth services expire at the end of 2024. It will take an act of Congress in an election year to make coverage of telehealth and telephone services permanent for Medicare. The final rule states that telehealth coverage will revert to prepandemic rules on January 1, 2025.

Strategies for Improving Global Surgery Payment Accuracy With Appropriate Use of Transfer of Care Modifiers

CMS has expanded the use of the transfer of care modifiers 54 (surgical care only), 55 (postoperative management only), and 56 (preoperative management only), which apply to surgical procedures with a 90-day global period when the surgeon performing the case is in a different group than those performing the preoperative or postoperative outpatient care. While these modifiers have been available, it is believed that they have not been used to the extent intended. CMS emphasizes the importance of appropriate usage to avoid duplicative Medicare payments for postoperative care when performed by a different provider (group) given the global payment structure. Slightly differing from the proposed policies, CMS finalized that modifier 54 (surgical care only) is required for instances within 90-day global surgical packages when a practitioner plans to provide only the surgical procedure portion of the package, including formal and other transfers of care. For modifiers 55 and 56, no policy changes were made, and they should be used only when there is a documented formal transfer of care.

Additionally, CMS finalized the creation of Healthcare Common Procedural Coding System code G0559, an add-on code for reporting postoperative care services provided to a Medicare beneficiary by a practitioner who did not perform the surgical procedure. The code was introduced to capture the time and resources required for these services. G0559 can only be appended to an office E/M service for new or established patients, is billable once during the 90-day global period, and has a final work RVU of 0.16.

Conclusions

Urologists and urology groups should be aware of the key provisions outlined in the MPFS final rule, as highlighted above. This summary does not cover all changes and updates, so reviewing the final rule itself is recommended for a complete overview. It is also essential for urologists and groups to stay informed about any upcoming changes, particularly those related to CF and telemedicine services, as they may impact practice operations.

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