Urology Coding Alert

CMS follows through on its previous proposals.

In July 2023, the Centers for Medicare & Medicaid Services’ (CMS) outlined key proposals for payment policies under the Medicare Physician Fee Schedule (MPFS) proposed rule for 2024. On Nov. 16, 2023, CMS confirmed those proposals, and the released final document now provides us with a more detailed understanding of what to expect in the upcoming year.

Continue reading to understand what 2024 has in store for you.

Expect no Change in Proposed CF

The bad news is CMS has finalized the conversion factor (CF) to be $32.7442, a reduction of $1.15, or minus-3.4 percent, compared to the 2023 CF of $33.8872.

According to CMS estimates, the specialty of urology will see an overall 1 percent revenue increase for 2024. For individual practices, the 1 percent increase may not be the case, depending on the practice type, mix of patients and types of procedures and services provided to their patients. CMS also estimates that there will be a 0 percent effect on facility payments and a 1 percent increase on nonfacility payments. However, don’t forget the third year of the Clinical Labor Adjustment will affect the practice expense payment for many services performed in the office setting. “The practice expense relative value units will be reduced again this year. For example, many benign prostatic hyperplasia [BPH] procedures performed in the office will experience a reduction in payment,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland.

Implement Split/Shared in 2024

The CY 2024 MPFS final rule also contains one of CMS’ most awaited rulings — its definition of split/shared visits and the additional decision to implement that definition beginning Jan. 1, 2024. Much to the relief of all that bill services to both Medicare and private payers, CMS has at last decided to finalize its definition to make the “substantive portion” of a split/shared visit “align … with the CPT^® [evaluation and management] E/M guidelines for this service.” The final rule adds, “These guidelines should be applied to determine whether the physician or [nonphysician practitioner] NPP may bill for the service.”

Per CPT^®, this means “if code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.”

Applying the substantive portion guidelines to code selection based on medical decision making (MDM) is a little trickier. Again, per CPT^®, “performance of a substantive part of the MDM requires that the “physician or other [qualified healthcare professional] QHP has performed two of the three elements used in the selection of the code level based on MDM.” This is usually satisfied when the physician or QHP has “made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management.”

If the physician or other QHP uses the amount and/or complexity of data element as one of the elements to determine the MDM level for the reported code level, however, CPT^® requires that “an independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP.” Even so, “assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan,” per CPT^®.

So, it appears at this time, “if the physician is able to meet the level for the code selected with two of the three columns of MDM, the physician will bill the service under their provider number even if the QHP/NPP is also able to meet the MDM level for the code selected with two of the three columns of MDM. There will be scenarios where documentation may be unclear who performed which component of the MDM. So, documentation clarity will be of utmost importance when two providers are rendering and documenting the visit,” according to Lori Carlin, CPC, COC, CPCO, CRC, CCS, principal at Pinnacle Enterprise Risk Consulting Services.

Add G2211 to Your Coding Arsenal in 2024

CMS has also finalized the addition of HCPCS Level II add-on code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established), which was active beginning Jan. 1, 2024. However, while you’ll be able to report G2211, CMS will bundle the service and you won’t be reimbursed for it.

“HCPCS code G2211 could recognize the resources inherent in engaging the patient in a continuous and active collaborative plan of care related to an identified health condition the management of which requires the direction of a clinician with specialized clinical knowledge, skill and experience. For urology, the addition of G2211 might be appropriate for a patient with urological cancer or significant urologic condition,” says Storck.

For further study: Find more information about using G2211 by going to www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf. Also, go to www.federalregister.gov/public-inspection/2023-24184/medicare-and-medicaid-programs-calendar-year-2024-payment-policies-under-the-physician-fee-schedule to download the CY 2024 PFS final rule.