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    Medicare final rule: Urologists’ pay set to decrease (again)

    Watch for reimbursement cuts for imaging, cystoscopy, TURP, and new code for rectal spacer

    Ray Painter, MDRay Painter, MD Mark PainterMark Painter


    It’s that time of year of again. As we wrap up 2017, it is time to prepare for next year. Urology was spared any significant changes in ICD-10 when that system was updated officially Oct. 1, 2017. In this article, we provide a summary of CPT changes for 2018, the Medicare Physician Fee Schedule final rule, and the final rule for the Quality Payment Program. 

    New CPT codes

    Effective Jan. 1, 2018, the American Medical Association-developed CPT coding system will contain one new code in the Genitourinary System. Two new codes related to Oncology testing for prostate cancer were added to the Molecular Pathology tier 2 codes (81541 and 81551) and two new Proprietary Laboratory Analyses (0005U and 0023U) were added. (We will save discussion on coverage and use of these codes for a subsequent article.)

    Also by the Painters: How to get reimbursed for BPH water vapor ablation

    Code 55874 (Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection[s], including image guidance, when performed) replaces CPT category III code 0438T and will be available Jan. 1, 2018 to report the insertion of SpaceOAR Hydrogel. Medicare has assigned the code a status of A (active) and relative value units (RVUs) for both the facility and non-facility setting as noted in table 1.

    Code 55874 Fee Schedule information

    The final rule for the 2018 Hospital Outpatient Prospective Payment System (HOPPS) has also established a payment pathway for the code, allowing possible payment in the facility in outpatient and ambulatory surgical center settings.

    Medicare Administrative Carriers (MACs) are allowed to develop specific coverage instructions in the form of either a local coverage article or a local coverage determination, but generally inclusion in both the Medicare Physician Fee Schedule and the HOPPS means that Medicare will cover the service if it is medically necessary. We encourage you to continue to monitor bulletins and MAC websites for any further reporting or coverage instructions. Private payer payment, as we all know, is not required to comply with Medicare decisions and must be determined on a payer-by-payer basis based on patientplan.

    Finally, a few CPT-related changes to standard x-rays for the abdomen and chest will also become effective Jan. 1, 2018. If you are providing these services, please review the CPT book. AUAcodingtoday.com will add new CPT codes to the database on Jan. 1, 2018. A list of all 162 additions to the system is available for subscribers as a download sheet on the landing page.

    Next: Physician Fee Schedule final rule

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.


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