Key takeaways from this episode

• The 2026 proposed rule splits the conversion factor in two, and both go up. Qualifying APM participants get a 3.83% increase to $33.59; everyone else, which is nearly all urologists, gets 3.62% to $33.42, with about 2.5% of that coming from the "big beautiful bill."
• Urology nets out at 0% overall: about +5% for office-based services and about -10% for professional fees in the hospital or ASC. The increase was funded by cutting work RVUs roughly 2.5% on non-time-based codes (most of the 50000 series) and cutting facility practice expense by about a third; roughly two-thirds of urology codes drop 5% or more at the facility rate.
• Watch work RVU-based contracts. The work RVU cut is small, but it adjusts year over year, so employed physicians on RVU contracts will feel it even where overall payment holds.
• Telehealth in the home still depends on Congress; the flexibility expires September 30, 2025. CMS proposes to make virtual direct supervision permanent (but end it for teaching physicians), remove frequency limits on hospital telehealth visits, keep home telehealth for RHCs and FQHCs through 2026, simplify the telehealth list to a three-step process, and continue paying E/M codes rather than the 980 telehealth codes.
• New remote monitoring and remote therapy codes cover the 2-to-15-day period. Practices no longer need 16 or more days of data to bill every remote monitoring service.
• 55700 is deleted for 2026 and replaced by nine new prostate biopsy codes, with big value cuts to the survivors. 55705 drops from 4.61 to 1.93 work RVUs, 55706 from 6.28 to 4.27, and 76872 from 0.69 to 0.67; the new codes range from 1.5 (each additional) to 3.81 (in-bore), with most around 3.
• New laparoscopic radical prostatectomy codes bundle limited or full bilateral pelvic lymphadenectomy, and Aquablation gets a work value of 10.25. Overall payment for the laparoscopic simple and radical prostatectomies falls 26% and 28%.
• TURP-family codes take 32% to 36% overall payment cuts at the facility rate, while Rezum is the big winner. 52500, 52601, 52630, 52648 and 52649 lose 25 to 26% of work value (52630 only 2.4%), but 53854 rises about 114% in the office to roughly $3,400 to $3,500, and cysto drops less than 5% in the office (about 7% in the facility).

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 251, recorded July 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Initial reactions and the split conversion factor

[00:00] Scott Painter: On this episode, an initial reaction to the 2026 proposed CMS rules. Stay tuned. Welcome to episode 251 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Let's dive right in. Mark, what are your initial reactions? I know you haven't had a ton of time to go through everything with a fine-tooth comb, but you've gone through enough to get your initial reactions on what's coming down the pike. How does it look for urology, and what are your thoughts? Let's hear it.

Mark Painter: I now have less hair than I had before, as a starting point. This has been a lot to go through, and there's a lot still to go through. In discussions with a few other folks, as we've been painstakingly tearing apart everything, the summary at the top level is not bad. The conversion factor for next year is going to go up a little bit. That's a change from years past, where we've been waiting until the last minute to see the conversion factor. So we don't have the same lobbying effort this year for "back to zero." I'll give you that piece of news first.

But it is going to be a little bit different next year in that, by statute, they are now required to split the conversion factor. There is going to be a conversion factor for what they call qualifying QPs. Those are qualifying practitioners, physicians that are part of a qualifying advanced payment model. So that's going to be those people in the heavy-risk models that get about 15% of their patients under a risk-model payment. A lot of you who participate in ACOs as part of your practice won't fit into this particular category. In fact, there aren't a lot of urologists that I know of out there who, as I read it, would fit as qualifying QPs. That conversion factor is going to go up 3.83%, to $33.59 next year. For the rest of the market, the non-qualifying QPs, the bump in the conversion factor is 3.62%, or $33.42 next year.

Where the money came from: work RVU and facility practice expense cuts

[03:00] Mark: So that's good news. The underlying reason why that is higher is a secondary issue, and that's where we start looking underneath the covers. It's a bit of a Trojan horse. A piece of this conversion factor bump is based on the big beautiful bill, which required a two and a half percent bump. The rest of the bump actually came because CMS is proposing some significant changes to the underlying work values, and that has shifted some of the costs in the system, allowing them to then turn around and bump the conversion factor.

Urology, they're projecting, has an overall impact of 0%. Even with the conversion factor bump, they're projecting a 5% bump for office-based urology, but they are projecting a 10% decrease for professional fees provided in a hospital or an ambulatory surgical center. That's really where the money came from to bump the conversion factor: going after the hospital. First, they went after procedural services provided by urologists, through the work RVU, in a small amount, but definitely something everybody is going to have to watch, especially if you're on a work RVU-based contract that adjusts year over year. Essentially, they looked at all of the work values for codes that were not, quote unquote, time-based. They considered E/M codes time-based, and of course they considered any code based on the number of minutes as a time-based code, and a few other codes, just like E/M codes. Those were untouched. But our surgeries, most of them, were adjusted down by roughly two and a half percent. You'll see an impact in your RVUs for services in the 50000-series codes, for the most part, and a few of your other codes that aren't time-based. I haven't yet been able to dig down enough to see if this impacted the injection codes and some of the other high-volume procedures that urology deals with for a lot of the care they provide.

The second reason the facility is dropping so much is that Medicare determined that now, with the majority of physicians being in employed situations, their services in the hospital and their services in the office also have a separate facility fee from the hospital, which ultimately ends up double dipping on the practice expense value. So they went back into the practice expense value for the facility, and they dropped it by about a third. This means a lot of your hospital payments drop. Many of you have heard me speak year over year, and know that when I get through the full analysis of the Medicare fee schedule, we usually pop up a couple of slides with the procedures in which the overall fee moved more than 5%. Usually that list is limited to about 15 to 25 codes. Last year we had virtually all of our urodynamics codes and all of the cysto codes on it. This year, when we go in and start looking at the decreases and we look at the facility rate, that number of codes is roughly two-thirds of urology-based codes, dropping in that range of 5% and higher. So that's where that 10% hit comes: the facility practice expense, plus the work RVU adjustment. That's one of the big underlying things we're seeing.

Telehealth proposals

[08:00] Mark: I'm going to jump over to telehealth, and then circle back to a few specific codes that were impacted more than the others. I do have one piece of good news, but I'll save that. The proposed changes for telehealth are interesting. I can start off by telling you that the proposed rule leaves in Congress's hands the extension of our current ability to provide Medicare services to patients in their home, regardless of where they're located. That currently expires on the 30th of September, and that is still in the hands of Congress, so we need to keep lobbying to make sure that telehealth continues for all Medicare patients after September 30th, and that would include 2026.

Now, Medicare, in its proposed rule, not being able to actually change the telehealth coverage for everyone, has made some very positive changes that we see as Medicare being supportive of telehealth. So we'll have to see what Congress does, keeping in mind that right now the telehealth extension for everybody goes away on September 30th unless Congress acts.

What Medicare is proposing is, number one, they're going to make permanent the ability for direct supervision to be provided by a physician immediately available via audio and visual means, and I should say physician or qualified healthcare practitioner. That has been in place since the pandemic; it was extended through the end of 2025, but now they are making it permanent. So that will allow direct supervision if a QHP, a qualified healthcare provider, is available via audio and visual means, not requiring that QHP to be in the facility. It's now in the facility or available by audio and visual when the service is being provided.

They decided that the same supervision does not apply to teaching physicians. That was part of the pandemic, but they are discontinuing audio-visual supervision for teaching physicians and requiring that teaching physicians be physically present in order to supervise and bill for those services.

They did remove the frequency limitations for telehealth hospital visits. That is something that would potentially continue, because the patient wouldn't be at home; they would be in a facility when those services are provided. So that one looks like it will be extended. And for those who are working in RHCs or FQHCs, which are specific designations in the Medicare program for underserved areas and federally qualified areas, they're looking at continuing the geographic flexibility, meaning patients could be treated in their home through the end of 2026, just in case Congress doesn't provide that extension. So for those of you who have patients in, or are part of, RHCs or FQHCs, you're going to be able to still provide telehealth in their home, even if Congress does not act.

The other thing Medicare decided is they were going to streamline the list of services approved for telehealth. Right now we have different categories and a five-step process that Medicare uses to add codes to the approved telehealth service list. They have decided to cut the approval process down to a three-step process, essentially eliminating some of the required efficacy and quality issues, leaving it in the hands of the physicians to make the determination as to whether or not a service that is on the telehealth list is appropriate for that patient and their condition. So it still has to be on the telehealth list and go through Medicare's evaluation process, but it might make it a little easier to expand that list. And they've removed the categories, so all of the services now are considered permanent, and it is left to the physician to decide whether it is safe and effective for that patient to receive telehealth, as long as the service is on the telehealth list. So that's one of the positives, that they moved in that direction.

They did decide, in preparation for Congress acting, that they still will not cover the new telehealth codes, the 980 codes. Those codes are excluded from the Medicare fee schedule, partly because Medicare basically can't extend the telehealth flexibilities that we have right now. So they're leaving those under E/M codes. If Congress approves telehealth, we will be using the E/M codes just like we are now. The documentation requirements will be as they are now, and we're still hoping Congress will come through.

They also expanded remote monitoring and remote therapy services. They did this in two ways. One is rule-based: they decided to accept some new CPT codes that are going to allow coverage of remote monitoring and remote therapy services provided by physicians or their staff in the 2-to-15-day period. Now we don't have to have 16 or more days for everything. We've got new codes that pay differently for those services. So Medicare, underlying, and in the absence of the actual approval from Congress, is really laying the foundation for telehealth to be a part of Medicare in the future.

The new prostate biopsy codes and their values

[16:00] Mark: Now, the last part I'll go over today. We still have to go through the changes they're proposing to globals and how globals are built, and a few other general areas, but I do want to focus on a few specific procedures. Number one, the new biopsy codes are valued and they're out there. We are going to see in 2026 that 55700 will be deleted, a code we used forever. That is going to go away, and it is being replaced by nine new codes. And then we're going to see some description changes and value changes relative to codes 55705 and 55706, which right now are the non-image-guided biopsy, any approach, and the biopsy for the transperineal stereotactic method. We're also seeing the values change significantly. 55705 is going to drop from a 4.61 work value to a 1.93 work value. 55706 is going to drop from a 6.28 down to a 4.27. We're also going to see 76872 drop from 0.69 to 0.67 as far as the work value goes. When we look at that from an overall standpoint, we'll have to give you those numbers on a different day as to what the overall impact is to the fees.

But we now will have new codes for transrectal ultrasound guided with ultrasound localization; ultrasound guided transrectal with MRI fusion guidance; transperineal ultrasound guided; ultrasound localized transperineal with MRI fusion for ultrasound guidance; a transrectal MRI-guided fusion biopsy code; and a transperineal MRI fusion biopsy code. Then we also have an in-bore CT or MRI guided code for a single lesion, and a CT or MRI in-bore targeted lesion code for the first targeted lesion. We have additional lesions, and then we have an each-additional for the MRI fusion or in-bore CT/MRI, and those are all guided to some extent. So we've got some additional guidance that we'll be putting out around these codes, and the final code numbers for those, once we see CPT come out. The RVUs for those codes range in value from the each-additional at 1.5 to the higher end, which is 3.81 for the in-bore. So anywhere from one to four, and most of them sit right around three. We'll have those values out.

Prostatectomy, Aquablation, TURP, cysto and Rezum changes

Mark: Some of the other specifics are very interesting. We are going to have two new codes for laparoscopic radical prostatectomy with lymph nodes bundled in: one for a limited pelvic lymphadenectomy, and one for a full bilateral lymphadenectomy. We didn't see a big change in our 55866 or those codes for the current simple and radical laparoscopic prostatectomies, but we are going to see new values and new codes for those. Those codes are going to range similar to where they were, as I mentioned, relative to current, but a little bit lower than we currently have with our 50% reduction, as that was probably the target of why Medicare asked for those codes to be bundled.

Then the other thing is we got a new code for the ablation. That Aquablation code came in with a work value of 10.25. In the process of valuing those, we did see some significant drops in the values associated with the revision of the bladder neck code, 52500; the 52601, the TURP; the repeat TURP, 52630; and the laser TURPs, 52648 and 52649. All of which will be decreased significantly, unfortunately, as we look at the 2026 values. We're projecting right now, with the proposed rule, work value drops in the 25 to 26% range. Now, the repeat TURP did not drop as much. It was only adjusted by the 2.4%, but with the facility drop, that overall payment is dropping about 34%; 32% for the bladder neck, 33% for the TURP, and 34% and 36% for the laser codes. So, significant drops there. Actually, I should hold my tongue and go back. We did see drops in the overall payments for the laparoscopic prostatectomies of 26% and 28% for the simple and the radical. We are going to see some drops in a few of the other codes in the prostate area, again in that 20% range in the overall payment, but the work value codes are staying in that 2.5% drop rate. So you can see that the underlying drops they put into place for the facility rates are, in fact, fairly significant with those adjustments to the practice expense.

When we look at overall payments, there is good news on a couple of things. One is our cysto drop this year in overall payment is not that significant. We're below the 5% range for the office-based, not for the facility-based; we're going to see about a 7% drop there. And then we did see a couple of things bump up. Specifically, one of the largest gainers for all RVUs was code 53854, for the Rezum, which actually is going up about 114% for the in-office, even though it's dropping about 8% in the facility, to an overall payment level, based on the new conversion factor, of somewhere around $3,400 to $3,500. So that's something that ultimately was in the win column. We also saw the 52235 and 53850 go up for the office setting by a little bit. So it was definitely not the most exciting read, and a lot to dig through. Sorry, I went into a lot of detail, but we'll be giving you more as we go through it, because there's a lot I left out.

Ray's question: the office versus the hospital

Scott: Ray, what are your thoughts? Any questions?

Dr. Ray Painter: It's just overwhelming at this point. But the bottom line, Mark: if you go to the hospital from your private practice, you're going to get a decrease in most of the procedures, and in the office you're staying the same or increasing a little. Is that correct?

[25:00] Mark: Yeah, that's what the overall projections are. We've got about a 5% increase in the office-based services we provide, and they averaged it out to about a 10% decrease in the facility, and that's using urology overall, obviously. If you're a laparoscopic or robotic prostatectomy surgeon, that's a bigger hit for you in your professional fees. Work values, not as big. So if you're on a contract based on work RVUs, it's not as big a hit, but it is a hit. But yes, the billing for robotic prostatectomies is going to see a significant decrease in revenue. Ultimately, we go back to what we've been saying for a long time: the trip to the OR is an expensive hobby, and it just got more expensive next year.

Sponsor, the PRS hub and final thoughts

[26:00] Scott: That is for sure. All right, Mark covered a lot in this episode. We're going to wind this up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. Also, we want to remind you that the PRS Coding and Reimbursement Hub is starting to be populated. If you go to prsnetwork.com/urologyhub, you'll start to see some information on various urology categories as well as pharmaceuticals and devices. We are working on updating that and getting it launched the rest of this year, so you'll be seeing a lot more information as we go along. All right, what do you think? Do you want to give some final thoughts, or are you good?

Mark: My final thought right now is, blah. Ray, how about your final thought? No, the only other thing I would add is that the unfortunate piece of all of this is that's not the only other shoe that could drop, because we still have PAYGO looming. That's another 4% that's out there, potentially hanging over everything in the Medicare world. So, to take the depression and drop it one more level, we've got a lot of lobbying to do.

Scott: That is so true. Ray?

Ray: It's getting more difficult to provide the care you'd like to provide, but just keep in mind that you have to pay attention to the details, because you're up in some and down in some. It's confusing, but in the end it is just detail, and pay attention.

Mark: All right, we'll keep digging. See if we can find some lipstick for this pig.

Scott: Yes, there is a lot to it, so there's a lot more, and we'll keep it coming. That's all we have for today. Take us out, Ray.

Ray: Happy coding.

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