Key takeaways from this episode

• The proposed 2027 conversion factor drops about 1.68 percent to $32.84 (1.19 percent to $33.1693 for qualifying APM participants). Last year's 2.5 percent bump was a one-year act of Congress, and CMS projects a combined minus two percent RVU impact for urology, split between work and practice expense.
• CMS proposes applying the multiple procedure payment reduction to E/M services billed with modifier 25. Only the highest-valued service on the day would be paid in full; an E/M-25 billed with a cystoscopy would be cut fifty percent, while an injection, catheter change or PTNS billed with a higher-valued E/M would take the cut instead.
• Comment against the modifier 25 reduction and push for a smaller MPPR. PRS sees no work RVU overlap in a separately identifiable E/M, CMS floated twenty-five percent as an alternative, and commercial payers in Michigan and Massachusetts have already tried this policy.
• G2211 would be eliminated and replaced with a HCPCS modifier paid as a percentage of the E/M code's total RVUs. ACO participants would get roughly double the adjustment (thirty-two percent), but the modifier still cannot be used when modifier 25 is on the E/M, and RVU-based compensation contracts will need to handle it.
• Practice expense methodology changes, phased in over 2027 and 2028, will hit technical components and urodynamics. CMS is dropping the 2015-based indirect cost index, and in-office cystoscopy codes take year three of the four-year supply pack phase-in.
• 51715 gains the bulking agent as a direct practice expense, valued at $1,175, for roughly a three hundred percent reimbursement increase. The associated L codes for the bulking agent are expected to be phased out, making the office setting more viable for that procedure.
• Prostate biopsy codes are being revised again, with descriptors focused on lesion-targeted fusion rather than fusion use alone. Expect a new code and changes to the each-additional-lesion codes, with documentation and templating implications to be covered in a dedicated episode.
• Telehealth stays essentially unchanged by statute, but CMS proposes group medical visits (two to ten patients, up to twenty-five) and would bar third-party remote patient monitoring. RPM and RTM staff would have to be practice employees billing under a physician with an established relationship; CMS also floated mandatory 99024 reporting, clinical lab fee schedule cuts, alternatives to CPT and the RUC, and new MVP measures for urinary incontinence plan, surgical risk assessment and bone density.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 296, recorded July 2026, with Scott Painter and Mark Painter of PRS Network.

Conversion factor and overall impact on urology

[00:00] Scott Painter: On this episode: initial reaction to the proposed 2027 rules for Medicare. Stay tuned. Welcome to episode 296 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, and wow, there's a lot to unpack in the proposed rule. Mark, do you want to get started? Let us know what you think.

Mark Painter: We'll start with the conversion factor. As expected, the conversion factor in the proposed rule is projected to decrease. We suspected this would happen because our 2.5 percent temporary one-year bump was an act of Congress, and Congress has not yet addressed this new rule or the fee schedule at all. So we're looking at the standard rigmarole related to budget neutrality. The average urologist, or the majority of urologists, will see a decrease in the conversion factor of about 1.68 percent, down to $32.84. If you're in a qualifying APM, the reduction is slightly less, at 1.19 percent, down to $33.1693. That's our jumping-off point as we talk about everything a little deeper, some of the reasons and some of the interesting changes Medicare is proposing.

Now, remember, this is all proposed. As we know, proposed rules tend to become final, but we do have the opportunity to comment, and we have seen some changes on different things. CMS was a little lighter in a lot of the things they addressed this year, proposing and inviting comments relative to everything that was put out there. So we'll have to see how everything shakes out. The other thing we've got to consider, at least with some of these, is that they actually put in some caveats, and I'll try to highlight those as we get to them.

From an overall RVU standpoint, Medicare is projecting a negative one percent for urology based on work RVU impact, and a practice expense RVU impact of minus one, for a combined impact of minus two. The bigger hit this year is on the non-facility side. You may recall that last year we saw the across-the-board adjustment to the practice expense on the facility side. Although Medicare continues to think there is some overpayment in the overlap between the facility and the physician, because of the fifty percent of physicians employed by hospitals, they didn't propose anything new this year that gives us any of those drastic drops. The other thing Medicare reiterated is that the 2.5 percent work RVU efficiency adjustment that went into play last year is a three-year circulating issue and ultimately will not impact 2027.

But there are some different things hitting across the board that are going to impact the revenue stream, and that aren't as visible on the RVU side if you're on an RVU contract and your contract doesn't take these adjustments into account. There are some big proposals in here that in some ways understate the impact across the board for urology. This is something we're going to have to unpack a little more, and we'll certainly do that as we go forward and give you little previews as best we can.

The proposed multiple procedure reduction for E/M with modifier 25

Mark: One of the biggest things proposed for next year is applying the multiple service payment reduction to E/M codes with modifier 25. What that means, the way they've proposed it, is that if an E/M with modifier 25, which currently is paid at one hundred percent, is reported on the same day as another procedure, so that modifier 25 was required, then the highest-valued service provided that day would be paid at one hundred percent. That could be the E/M code. Every other procedure billed on the same day that is subject to multiple payment reductions, now including the E/M code, would be reduced fifty percent.

So take a typical visit where you saw a patient for surveillance on bladder cancer, saw a recurrence, and sat down with the patient. The cysto would be billed, and the E/M with modifier 25 would be billed. The cysto, being the higher-valued code, would be paid at one hundred percent, and the E/M, as the lower-valued code, would get paid at fifty percent. Conversely, if we look at an injection procedure visit, a catheter change visit, or even a PTNS visit, those are all lower-paying than the E/M code, so the E/M would pay one hundred percent and your injection code or PTNS code would be reduced by fifty percent.

That's a big one. It deserves comment across the board, and it's an impact that really isn't taken into account in the calculations we see from Medicare. There were some overall projections Medicare hinted at relative to that reduction in payment that allowed them to adjust the conversion factor and maybe a few of the RVUs, but it doesn't appear they took it into account in the general impact in that two percent. They did not list urology as one of the higher-impacted specialties for this proposal, but it is definitely going to be an impact to urologists, and probably not all of them equally.

In my estimation, there are a number of issues wrong with this. Number one, the fifty percent reduction applied to multiple procedures is really a reduction in work and practice expense. But because many multiple procedures are provided in a facility setting, the majority of the impact is work RVU. When we look at the definition of modifier 25 and the work effort paid for under modifier 25, I don't see any work RVU overlap, and I don't think that should be calculated for a reduction at all. I can see Medicare's general argument that administratively you only have to send out one bill for the day, you only have one check-in, so maybe there are some direct and indirect labor costs that might be somewhat reduced because of the same-day service. But fifty percent is far too high.

I expect the AMA and most of your surgical specialties will weigh in against this, but I think this is something we should all weigh in against, and at the very least lobby for a different reduction. Medicare acknowledged this a little in the published discussion of the proposal, saying they might use a different MPPR, and instead of fifty, they mention a twenty-five percent reduction. So it is going to be something they look at. We need to make the arguments in a way that makes sense to Medicare, and hopefully at least stop this. The other thing this opens the door on is: what are commercial payers going to do? We've already seen many commercial payers try to implement a policy like this in Michigan. In Massachusetts, I believe they've already implemented it. They fought it off a couple of times in Michigan, but this is going to open that door now that CMS has even proposed it. We're going to see it across the board.

Scott: Quick comment. When you were reviewing this, you noted that this was mentioned in a very small part of the rule. Out of the thousand-page rule, it was just a paragraph or so. I find it interesting that it kind of slipped in there.

Mark: It is slipped in there, and it didn't really come up as a big verbal thing. They did acknowledge it as something folks would probably push back against. And I think there are some other impacts that are a little more subtle. Medicare already has a work RVU adjustment programmed into all procedures because of the potential of an E/M on the same day. If they implement any reduction, they need to go back and fix that in the work RVUs for many of the procedures. So this impact is broader than it looks. And you're right, Scott, they didn't give it the space in the rule that the impact really warrants.

Scott: Same thing, it seems, with the next topic you're going to bring up.

G2211 replaced by a modifier

[11:45] Mark: Yeah. G2211 is one of the codes we've been talking a lot about since it came into Medicare a few years ago. This rule proposes eliminating G2211 and replacing it with a modifier, a yet-to-be-introduced modifier in official HCPCS language. They are raising the rate, and they are looking at it as maybe a better reflection of the G2211 relative to the work RVU assigned to the E/M code. The payment is now going to be a percentage of the total RVUs associated with the E/M code, so it changes how much you're paid based on which E/M code is being charged for that visit. Their argument, of course, is that a more complex E/M visit has an associated complexity in that long-term care component. That's a good thing. It could be a big impact for urology in the positive direction, and the general concept seems supportable, but it will change a number of things in how we handle this in the EHR.

The other thing everyone is going to need to consider is what this does to your contracts. If you're paid on a contracted RVU production rate, how are your employers going to add that work RVU adjustment in based on a modifier? And is that demand to add the modifier adjustment going to open the door to looking at the fifty percent reduction for multiple procedures, or reductions based on a 78 modifier, if they're not already doing that? It does help on the modifier 22 argument, so if you've got that in your contracts, that's something they can programmatically handle. But if that's a new concept, it may be a bit of a Pandora's box as you look at the potential up and down on work RVUs across the board. The volume associated with G2211 may in fact make a difference there. And interestingly, for practitioners in an ACO, they're going to make that long-term care adjustment much higher. They're going to double it, at thirty-two percent. So if you're in an ACO, the G2211 replacement modifier is going to be even more important.

[16:49] Mark: Just to be clear, we still will not be able to use the modifier if modifier 25 is being applied to the E/M code. So it's not going to save us at all relative to the reduction in payment that modifier 25 is going to see.

Practice expense methodology, urodynamics, cystoscopy and prostate biopsy changes

Mark: There are a few other changes underlying the RVU side, and a lot of this is technical, so I won't go into too much detail. But we did walk through some of the methodology currently used to develop the practice expense and the work RVUs. You heard a little of that commentary related to the impact on the work value for same-day E/Ms. There is a fairly detailed description of how Medicare comes up with the practice expense and the work values, and one of the bases in the practice expense calculation is an indirect cost of practice index, based on a study done back in 2015. They're proposing to get rid of that, and several steps in the overall calculation of practice expense, but that one's the biggest. Because it is a big impact, they are going to phase it in over two years, so any practice expense unit in the system that's significantly impacted by the new methodology will only be adjusted halfway to its final value in 2027, and then finished in 2028. Then they're going to add a stabilizer to try to make some of these adjustments less impactful as they move forward. In the end, this is going to impact a lot of your services very differently. That methodology change is behind the scenes, and you'll see it hit things differently.

The other thing they focused on quite a bit is codes with the PC and TC breakdown. That is going to impact the practice expense for some of your technical components. We've got a glimpse of that, and we'll do a more in-depth breakdown of the RVU impact at another date. But the preliminary look is that urodynamics is impacted by that indirect practice expense cost, and that changed significantly. So we'll see some drops in urodynamics reimbursement as we move into next year. We'll also remind you of the impact of the supply pack for in-office cysto procedures. For 2027 we are in year three of the four-year phase-in, so we're going to see once again a bit of a drop in the cystoscopy family of codes.

We are going to see another revision to the prostate biopsy codes. We'll talk about the financial impacts on another podcast, but we are going to end up with some changes in the CPT descriptors that will impact both the documentation and the selection of these codes. I think the impact is going to be relatively minimal for many of these changes because of some of the stated rules and AUA positions on non-lesion-focused prostate biopsies. But the verbiage is changing to focus less on whether fusion was used and more on whether fusion was used to target specific lesions. At least from the regional biopsy standpoint, fusion won't make as much of a difference, but it will make some difference relative to the lesion-based codes. And there are some changes for the each-additional-lesion coding we'll need to take into account. We'll give you focused information on these codes in a session down the road dedicated to prostate biopsies, because we're going to get a new code and some shifts in existing codes.

Bulking agent cost added to 51715, and an overall rating of the rule

Mark: One of the bright points in the proposed rule is an update to the 51715, the injection of a bulking agent. It looks like Medicare has been won over as far as adding the bulking agent, based on invoice cost, as a direct cost. So we're going to see a significant bump in the value and reimbursement assigned to 51715, which will now include the cost of the bulking agent. Specifically, the bulking agent cost was tagged by Medicare at $1,175. That's going to be a big bump, about a three hundred percent jump in reimbursement for 51715, and we're probably going to see the associated L codes for the bulking agent phased out in this change. That will be helpful next year for moving that service into the office setting for those of you who do that. There are a couple of other random interesting things, but Scott, I'll ask for any questions or comments you want to make on what we've talked about so far.

Scott: The only question I have is, when you're reading through all this and thinking about the urology practice, what's your overall feel about the proposed rule? Is it a bad thing or a good thing? How does it rate, just as a barometer check?

Mark: I have to say the proposed fifty percent reduction on modifier 25 E/M codes is a big negative in my opinion. I don't think they factored that in correctly. I hope that's one of the areas where we can make an impact, and I'm worried about the application in the private sector. To me, that's a big strike against the overall proposed rule. Some of the other information in here is, for lack of a better way to say it, the expected issues as they relate to the update from one year to the next. The proposed negative conversion factor, we always see that. The proposal on the practice expense and indirect costs is going to be an interesting hit, with the shift in how they're going to address the technical components. Again, not what I would consider positive, so those all weigh on the negative side. Otherwise, I would put it as another year, another set of increasing focuses that are going to cause us to make some shifts in our projections. There are some positives, and that happens every year. So I'd put it as slightly below a regular year. In general, the presentations I give every year end up not being the most positive, except for maybe 2021, when we saw an eight percent increase because of the E/M code change. So it's not the worst of all things. Last year I would consider horrible, with the facility impact and the adjustments to the RVUs across the board. This is nowhere near that bad. It's not the worst, it's not the best; it's about average.

Scott: I think that's a good assessment. And I know when we were preparing for this, you already had an argument we're going to submit on the modifier 25 reduction.

Mark: Yeah.

Scott: All right, let's keep going.

Telehealth, group visits, remote monitoring and other proposals

Mark: Some of the other things that are out there. Let's start with telehealth. Telehealth is going to remain the same in 2027 for the most part. We're not going to see a big change here; that was statutory direction from Congress, so CMS didn't have a lot of wiggle room. They are going to add a couple of interesting things we'll have to explore more deeply, and one of them is the potential for group medical visits. This caught my eye going through this. There is now a potential to do group medical visits with patients who consent to be on a group medical call. In Medicare's eyes these calls will typically last between one and two hours, typically have two to ten patients, but could be up to twenty-five in certain circumstances, and will be focused on patients with the same chronic medical condition. Patients will have to agree to have their personal information discussed in these groups, but Medicare believes the exchange of information among the patients will be a valuable addition to the clinical exchange. They're thinking there may be more than one person from the physician office involved, the physician plus maybe some support staff to help with development of plans. It will require documentation in each individual patient's chart, and you will be able to bill this code for each patient who attends. That one is very interesting. We'll have to see if it stays in the mix.

Pseudo-related to that, CMS is taking a look at remote patient monitoring codes. They've flagged the use of third-party groups to provide remote patient monitoring and remote therapeutic monitoring, and have proposed that this will no longer be allowed under Medicare: anybody providing remote patient monitoring will be required to be employed by the physician practice, and these services can only be provided and billed under physicians with an established relationship with the patient. That's not a code a lot of folks use, but there are some codes that may be affected by that ruling.

Then a couple of other things that are more global in the comments CMS makes, some of which they make every year. One is global surgeries. They're going to stop collecting data the way they have, which focused on a few states requiring larger practices to report the 99024. They floated the idea, but did not make it a proposal for 2027, of requiring every practice to submit every follow-up visit with a 99024, even if we're not getting paid for those services. I didn't like to hear that, but we'll have to see if they bring it up. As you know, Medicare has been focused on global procedures for a long time. There's also additional focus on the clinical lab fee schedule. Now that some legislative protections have expired, Medicare is looking at making some reductions in the clinical lab fee schedule, and we'll have to dive into that a little deeper.

Then of course there's Medicare's annual mention that they really don't like the RUC, they really don't like CPT, and they're looking at alternatives to both of those programs and to the nomenclature of CPT as the base for Medicare. They mention that routinely every year, but obviously this has been a target for the current administration. The current Secretary of Health and Human Services has very publicly stated that he's not a fan of CPT and would like to see an alternative system developed, and Medicare is encouraging people to come forward with that. They're also thinking about changes to payment reductions and frequency limits. All of these are loosely floated. And finally, we should mention the MIPS and MACRA program. We did get a few new measures proposed in the MVP program: one for urinary incontinence plan, one for patient-centered surgical risk assessment, and then bone density. All of those are essentially moving from single measures into MVPs, which are more group measures and might provide something more to look at.

Sponsors and final thoughts

Scott: You certainly gave us a lot to think about and provided a good summary of what's going on with the proposed rule. I appreciate all that information. I think we're going to wind this episode up. We want to make sure you understand that we are going to dive into these proposed rules, the values, the RVUs and all of that in upcoming episodes, so we will continue to break down what's coming down the pipeline. We also want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. Also, we want to thank UroGen, manufacturers of Jelmyto and Zusduri, for supporting this episode as well. You can go to jelmyto.com or zusduri.com for more information. Mark, any final thoughts? I know you gave a summary, but do you have anything more to add?

Mark: With what we've got coming our direction, I think it's more and more important for individuals to work through their societies and organizations, and in conjunction with them, with comments of their own: really well-worded commentary on the proposed rules that are not in favor of urology, as well as support for those that are in favor of urology moving forward. It's time to get a little active and push back on Medicare. As we know, Medicare has a great deal of influence beyond what happens in your Medicare day-to-day lives, obviously Medicare Advantage plans, but even beyond that. So we want to keep an eye on that. We will be discussing this with others. This was our initial crack at digesting this ginormous document with all of its very detailed discussions and changes, so stay tuned as we dive deeper and pick it apart. And again, it is in fact a proposed rule, so we'll have to see what happens in the final rule and where the comments lie. I also apologize for the background noise. I'm sitting outside today; it's actually a pretty nice day here in Colorado in the shade, not in the sun. It's a little hot, but we had to relocate for this one.

Scott: One thing I will remind you of is that the Urology Advanced Coding and Reimbursement Seminar registration is open, and we have a seminar coming up in December in Las Vegas and in January in New Orleans. At those two seminars we should have a lot more information on what's actually been adopted, and we'll have the final rule, so we'll be going over that in the seminar. We encourage you all to join us and really prepare your practice for all the things coming down. I know there's a lot you have to deal with on a day-to-day basis in your practice, and planning for the future sometimes gets pushed back, but we want to help make sure you're prepared for 2027 and beyond, and attending the Urology Advanced Coding and Reimbursement Seminar can help you do that. Also, the PRS Coding and Reimbursement Hub is being updated and more information is being added to it. You can check out the hub at prsnetwork.com/urologyhub, where you'll find information on various categories, how those categories are impacted by coding and reimbursement and what you need to pay attention to, as well as products associated with treatment for each specific urology category. That's all we have for today. Thank you all for listening. Take us out, Mark.

Mark: Happy billing, coding, and planning.

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