Welcome to the AUG's 2025 Coding Webinar. Today's webinar is titled 2025 Coding Webinar, Vital Changes Impacting Your Reimbursement. This webinar is presented by various members of the AUG's Coding Committee. Our primary speakers are Dr. Jamaica Price, Dr. Stephanie Molden, Dr. Emily Davidson, Rachel Hollander, and Dr. Jacqueline Munoz. Before we begin, I would like to view some housekeeping items. This presentation will run around 60 minutes and the last 50 minutes will be dedicated to Q&A. This webinar is being recorded and live streamed. A recording of the webinar will be made available via the AUG's eLearning portal. Please use the Q&A feature of the Zoom webinar to ask questions to our speakers. You can submit questions at any time during the webinar and we'll answer them at the end of the presentation. Use the chat feature if you have any technical issues. AUG staff will be monitoring the chat and can assist. We'll first hear from Dr. Jamaica Price. Dr. Price, you may begin. Hello everyone and welcome to the 2025 Coding Webinar, Vital Changes Impacting Your Reimbursement. I'd like to thank everyone for carving out time in their busy schedules for us to learn about these important updates and most importantly to ensure that we have the knowledge to empower ourselves and improve our practice reimbursement. As far as for the disclosures, again, the following speakers report the below potential conflicts. In addition to myself, Dr. Molden and Dr. Jacqueline Muniz have no actual potential conflict of interest in relation to this presentation. I want to start off with just a brief overview of the position fee schedule changes. The conversion factor update for the final calendar year 2025 is $32.3465. This actually represents a 2.83% decrease from the 2024 conversion factor of $33.2875. Just to keep in relevance of what that means, this is actually the fifth year in a row of roll cuts to the conversion factor and that illustrates the continued impact of no inflationary updated embedded in our current position fee schedule, an issue that your stakeholders, including your AUG's leadership, continue to press Congress to address. As of March 11th, Congress has not enacted legislation to mitigate any or all of the 2.83% conversion factor cut that went into effect beginning this January. I know in the past they have, however, they have not this year. So please keep that in mind. There might not be a buffer that has happened previously when this cut happened last year. Just to go over for the specialty impacts, CMS summarizes the aggregate impact of finalized policy changes related to CPT code level valuation and what this means. So in other words, these specialty impacts, they don't actually reflect that 3% cut to the conversion factor that I just talked about in the other slide. This is actually specialty impact wise as far as certain codes that actually got devalued. So a practice expense RVU reflects the cost of the non-position labor and the expenses for the building space, your equipment, and your office supplies. Your malpractice RVUs actually reflects the cost of your malpractice insurance for each procedure or service that you do. And then work RVUs, which everyone's more familiar with, accounts for the provider's work when performing a procedure or service. And please remember that your work RVUs typically account for 50% or more of the RVU total for a given code, and that's probably why the majority of us are very familiar with work RVUs. So in regards for the specialty impacts, it was actually negative 1% for OB-GYN, unfortunately, and 0% for urology. Just an update on the supply pack. So interested parties, including the RUC, have identified numerous discrepancies between the aggregate costs of some supply packs and their individual item components. And so they've urged CMS to rectify these errors. And so for three of these supply packs, there's been significant price changes. The nice news is that CMS will actually phase in these updated prices over four years to minimize the disruptive effects that it will have on the RVUs due to the significant number of services that actually use these common packs. So the four-year phase in is inconsistent in how CMS has phased in other changes with significant redistributive effects, including the recent supply equipment and clinic labor and pricing updates. So CMS did not finalize pricing updates for another 10 supply packs as identified, but they'll likely revisit those in the future. So what does that mean? So the packs that probably will affect us the most, there was a finalized 67% price cut for the urology system visit pack, which is priced into a lot of the value of the urogynecology codes, right? So this decrease will actually be phased in over four years, starting in 2025, and it'll end in 2028. So for right now, for a urology system visit in 2024, it was around $113.70. The new price that was finalized is down to $37.63. But like I mentioned, this is going to be phased in over four years. So for 2025, it'll be $94.68. In 2026, it'll be $75.67, and so on until they get to calendar year 2028. The good news is CMS did not finalize an 86% price cut for the pelvic exam pack, which is priced into the value of more than 200 codes. However, like we mentioned, CMS may revisit this in the future. So just keep that in mind. Now, with that, I will actually turn it over to Dr. Molden regarding the 2025 transfer of care coding updates. Good evening, everyone. So these are some interesting codes we're going to talk about that probably most of you are not familiar with, our coding changes. So we're going to talk about some changes to the transfer of care modifiers, which most of us have not been utilizing, but may come into play near you. We're going to understand their impact on the 90-day global service. We'll talk a little bit about this new HCPCS code, G0559, and what that means. And we'll come up with a couple examples of where some of these codes may be utilized. So, overall, we're all familiar, hopefully, with 90-day global packages. And with any surgical code, typically, there is an associated global surgical package, especially with our larger surgeries. And those codes or those packages include the preoperative care, usually one or two days before surgery and the day of, the surgical procedure itself, and the 90-day global package. And then postoperative care, up to 90 days, depending on the procedure, or maybe zero days, for instance, for cystoscopy-type procedures. They're assigned to most major urogynecology services, but during that care cycle, there may be a transfer of care where different providers share responsibilities. However, not within the same group. These codes do not pertain if the care is within the same group or same tax billing ID. So, there's three transfer of care modifiers, the 54, 55, and 56, which currently were really only used with formal documented agreement transfer of cares that were planned, basically, ahead of time, which were documented in the chart as an expected transfer between parties. Documentation was required for these formal transfers to be in the discharge summaries or the hospital ASC records or some sort of letter. And then the transfer of care was required to be in the discharge summaries or the hospital ASC records or some sort of letter. And then the transfer of care was required to be in the discharge summaries or the hospital ASC records or some sort of letter. And looking at the 22 Medicare data, most of the modifiers were really only being used in ophthalmology. And there was a very inconsistent use of the 54, 55 modifiers and very rare use of the 56. In 2025, the update includes transfer of care modifiers, which are very rare. So, the transfer of care modifiers are very rare. In 2025, the update includes transfer of care modifiers, but it doesn't have to be formally documented. There's an informal transfer of care that is allowed to occur now as well. And this also helped expand reporting beyond ophthalmology. Again, it would be used in any of your 90-day global procedures if the care is by more than one provider within different groups. We talked a little bit earlier about the relative value unit, so now we're a bit more familiar with that. And that obviously predicts our reimbursement. The transfer of care modifiers here are going to split that global payment. So, instead of getting the entire fee that you would normally get for the RVUs, it's going to be split. And that's because they are not providing the pre- or the post-operative care for that patient, for instance. The 55 modifier would be added on if the provider is only doing post-operative care. And the 56, if they're only doing pre-operative care, which would probably be more rare. The HCPCS code, G0559, will be reported by physicians who did not perform the procedure within the global package, but related post-operative care is provided during that global period. And that's in the absence of a formal transfer of care. So, if it's a formal transfer of care, you're billing the surgical codes with the modifiers. However, if it's an informal, say it was unexpected or just wasn't formalized in an agreement of some sort in the documentation, it would be reported with the E&M visit for the post-op care. So, the normal visit that it would be billed if it wasn't post-operative, for instance, the E&M level, you know, 1 through 4 or 1 through 5, reported with the G modifier. And with or without modifier 54. So, CMS has identified approximately 180 codes that may be affected by this change. So, this is something you want to look at your own practice policy or your own practice style and if this is something you might utilize. Many of us may not utilize these codes, but some may. And you want to start identifying which codes this may affect for you. Medicare is estimating an $150 million reduction in reimbursement by utilizing these codes. So, obviously, this is why they were interested. They've been trying to unbundle post-operative care with the 90 late global periods for a very long time. And this has been their kind of foot in the door to try to do some of that. Everybody's fought against it. So, for now, this is the only way they are able to unbundle anything. The only way they are able to unbundle anything in the post-operative package. This is giving you an example of coding. What, you know, the payment facility versus non-facility pre-op, inter-op, and post-operative portions of the care are for the RVU system for these codes. So, you can see in intercoporaphy, interoperative care is 74% of the payment, whereas pre-op and post-op are 12 and 14%. And so, if you only did the interoperative portion and apply the appropriate modifier in this instance, you would only get the interoperative 74% payment for that RVU. So, the G code is used when the care, again, is by a different practitioner, once per 90-day period. It can only be reported one time. Again, this cannot be used by a provider in the same group. It must be a different group, different tax ID, essentially. So, it can be the same specialty as long as it's a different group. It would be listed separately in addition to the E and M visit in this situation and requires the following elements. So, the code incorporates payment for reading the available surgical note because presumably this person did not do the surgery or maybe not even understand it if they're in a different specialty. They have to understand the success of the procedure, the anatomy, potential risk and complications. They may need to do some research to understand the normal post-operative course and potential complications. Evaluate and physically examine the patient to determine if the post-operative course is appropriate and then communicate with the original provider and practitioner who did the procedure if any questions or concerns arise. So, all of that is included in being able to utilize this modifier or this G code. The WorkRVU is .16. It's only approximately a $9 increase. So, this is actually less than the new codes that we are able to utilize for chronic care and so forth that you'll hear about. But it's only $9 increase to an average for CMS payment for the E and M code. So, it's not much. Keep in mind it's going to reduce the procedure surgeon's payment quite a bit. So, practitioners must ensure proper modifier usage. You have to clearly document and outline the post-operative care responsibilities to utilize this code. We all need to train ourselves and our billing teams to make sure everybody's on the same page as these codes are being utilized and then monitor claim denials and reimbursement. So, example one. Let's first say that a patient undergoes a sacroculpopexy by a surgeon in a referral hospital. The patient then returns to her rural hometown where perhaps the outpatient gynecologist she sees is then seeing her at a separate practice and is taking care of her post-operatively. In this case, there's a formally documented transfer of care agreement between the surgeon and the patient. In this case, there's a formally documented transfer of care agreement, because they knew this ahead of time and had planned for such, between the operating surgeon and the receiving gynecologist. The operating surgeon would bill the normal code for sacrocopal plexi but would add modifier 54. The receiving gynecologist in this instance would also bill the sacrocopal plexi code but with modifier 55. Example two, here's an unexpected transfer of care. A patient undergoes a vaginal hysterectomy performed by the urogynecologist, and two weeks post-surgery develops a fistula. Due to the complexity of the condition, the urogynecologist refers this patient to a urologist in a different group practice. And in this situation, there is no formally documented transfer of care agreement between the surgeon and the receiving urologist, as this was unexpected. In this situation, the surgeon would bill the operative code of CPT 58260 with the modifier 54 again, but the receiving urologist, because this was unexpected and not a formal transfer, now bills the E&M visit with the GE code of G0559. So that's the difference in which to use when. It's a little bit confusing, and it's new to us. I'm sure there's gonna be issues, but this is what we're supposed to do. So CMS has expanded the transfer of care requirements to formal and informal. They've added the new HCPCS GE code for post-operative care outside the original surgical group. And there's an increased documentation and compliance that are necessary to back up the care. And obviously some financial administrative impact will be expected as the surgeon would lose part of that global package surgical fee, while the physician receiving the transfer gained a slight increase in payment. All right, shifting a little bit, we're gonna talk about the updates for telehealth as of this calendar year. So as you all know, telehealth was expanded into more broad use during the public health emergency of COVID-19. And subsequently, even after the end of the public health emergency, there have been subsequent extensions that have been approved through congressional action. And at the end of 2024, they said that in the final CR of that year, that they would have a final extension to March 31st of 2025. While we anticipate ongoing bipartisan support and with recent as of March 8th, the House Appropriations Committee did release a draft continuing resolution, which would maintain the current Medicare telehealth flexibilities, including the broad use of telehealth, not restricting to mental health or substance use issues through September 30th of 2025. Really, this extension would provide additional time for Congress to deliberate on more permanent telehealth changes. So while we are still in flex waiting for Congress to see what's gonna happen, there are some relevant changes that we do know of as of this year. And those are really about how we are supposed to be billing for telehealth. So the way previous billing worked for virtual visits, including audio, video, or video visits, or audio-only visits, sometimes called telephone visits, in the past was that audio-video visits would be billed using the relevant E&M code based on time spent or medical decision-making as if the patient was in the office, and then the relevant modifier placed by the coders team. And that was really based on all of the time spent with the patient. Audio-only codes were previously billed with these so-called telephone visits you could only bill for the active telephone time and only restricted to established-only patients. Both, oops, both of these are actually no longer accurate. So what happened as of January 2025? So the CPT codes for those telephone visits expired as of January 1st of this year. The AMA also created 16 novel CPT codes, 9800 through 98015, eight for audio-video or video visits, eight for audio-only visits with four levels of medical decision-making for each new and established patient. While these have a current inactive status for CMS reimbursement, these are valid CPT codes. There is also a 17th code, that's 98016, which is a valid and active CPT code that is an audio-only quick check-in code for less than 10 minutes spent on the phone with the patient. So this is a summary with relevant RVUs and CPT codes for all different types of telehealth visits, whether it's new or established patients based on levels of medical decision-making and new and established patients visits. So specifically, how would you bill a synchronous audio-video visit? Just as if the patient was in the office, you would select the appropriate E&M level code based on new or established status, as well as the medical decision-making or time spent, including all the time spent on the day of the visit, whether it was charting or pre-charting, just as if the patient was in the visit. And then no modifier is needed because these codes are specific to telehealth visits. So no code modifier is needed for this. For audio-only visits, again, there are new visits and established visits that have their own CPT code. And if you're using time, at this time, we are recommending you document all the time spent on the day of the encounter, like in-office visits. But if you are spending less than 10 minutes of medical discussion with the patient, you need to select the quick check-in code, the 98016 code. Now, one important criteria is that previous CMS guidelines did not allow any new patient visits to occur by telephone or audio-only. And our recommendation is that before you offer new audio-only visits, investigate with your payers what the status is. We do anticipate future CMS coverage with this, which, of course, other payers are likely to follow, but make sure that you use new patient audio visit codes with caution. So there's always a concern about should we actually do audio-video visits or audio-only visits? And there has been a lot of concern, especially at my institution, about we are losing money on these visits and the reimbursement is not adequate for this. And that's really not true. So this is a summary of both in-person audio-video and audio-only codes. And you can see that the only exception being a level 5 established patient, there's actually no difference between in-person and audio-video visits. And there is only a slight reduction between in-person and audio-only visits. To further look at that a different way, again, the audio-only new visit is not recommended for use at this time. But to look at this, the actual percent difference is very small. So specific to CMS, for calendar year 2025, CMS is actually not reimbursing these new telemedicine codes, all of these codes that I just spent a lot of time talking about because they have that invalid or inactive indicator status. What is likely happening on everyone's coding side is that there will be internal communication for your coding team, or there will be kind of logistic corrections in the back that will use the existing office outpatient EM codes with appropriate modifiers for video or audio designation for CMS patients at this time. So a little bit broader scope of things is that, at least at this time, interactive telehealth is no longer restricted to mental health disorders and other rural designations that we have. There used to be a restriction for. Other important updates are that if clinicians have a telehealth practice where they see patients while they are physically in their own home, they are allowed to use their practice address on Medicare forms for their site of practice. Another important thing is that CMS will continue to allow direct supervision for procedures or care that require direct supervision through virtual two-way real-time audio-visual technology, at least through December 31st of this year. It will also continue to allow supervision of virtual care for resident delivered care for those of us in teaching institutions, but that is required by three-way virtual contact and at least through December 31st of this year. And also CMS will permanently allow virtual direct supervision with services typically performed in their entirety by auxiliary personnel, things with indicators 599211 as an example. So in summary, coding for telehealth eventually should be aligned to be similar to in-office coding based on medical decision-making and time. All telehealth visit types and levels of service have their own novel CPT code with the exception that audio-only visits with less than 10 minutes need to use that quick check-in code. At this time, we recommend restricting audio-only visits to establish patients given their predominant payer restrictions, including CMS restrictions. And RVUs are fairly equivalent for care between in-office, audio-video, and audio-only. And telehealth continues to be an essential part of modern healthcare and should continue. And August encourages you to contact your representatives and senators to voice your support on enshrining CMS coverage of telehealth in the future. Next, I'll be talking about the G2211 add-on code. This code is for long-term care of a complex or serious condition. It must be reported with a new or established patient E&M visit as the base code. You do not need any additional documentation. However, you must document the reason for billing the E&M that you're using. And beginning in 2025, G2211 can be billed with an E&M base code, even if it's by the same practitioner on the same day as an annual wellness visit, vaccine administration, or Medicare Part B preventative service, like a pap smear. It generates approximately 0.33 work RVUs, which adds up to approximately $16. It's not allowed with procedural or CPT visits and not allowed with the non-CMS new telehealth visits that we just talked about. It is still allowed with the original E&M CMS telehealth visits, and it's not allowed with post-operative visits or the 99024. And the second opinion, the E&M CMS telehealth visits, and the second opinions without any plan for long-term care also do not qualify. Since this can get a little confusing, I have several examples. The first example is a patient who presents for her Medicare annual wellness visit and reports new onset urinary urgency and pelvic discomfort. The physician performs the annual wellness visit, including reviewing the medical history, medications, fall risk, cognitive function, and creating a prevention plan. During the visit, the patient expresses concern about worsening urgency, frequency, and pelvic discomfort. So the physician also performs a focus history and exam, evaluates for potential causes, and discusses treatment options. The provider must bill an E&M code with the modifier 25 to indicate that the E&M service was medically necessary and distinct from the annual. The G0439 is billed for the Medicare annual, and then G2211 is billed because the physician is managing a chronic complex condition, which is the urinary dysfunction, requiring ongoing management needs. For the second example, a patient presents for evaluation of prolapse. She reports symptoms of vaginal bulging, pelvic pressure, and difficulty emptying her bladder. The physician performs a detailed history and pelvic exam, confirming stage two prolapse. The physician discusses treatment options, and the patient elects to continue conservative management. Since the patient is due for her cervical cancer screening per Medicare guidelines, the physician also performs a screening pap smear. You can bill an E&M code with modifier 25 to indicate that the E&M service was medically necessary and distinct from the screening pap smear. The pap smear collection is billed under Q0091, and G2211 is billed because the physician is managing a chronic complex condition, prolapse. For example three, a patient presents for evaluation of urinary incontinence and difficulty voiding. Conducts a comprehensive history and physical, including review of medical history, medications, and prior treatments or surgeries. The physician also performs a pelvic exam and bladder assessment. The physician determines that the patient has acute urinary retention and performs straight catheterization during the same visit. You can bill an E&M code with modifier 25 to indicate that the E&M service was medically necessary and distinct from the straight catheterization procedure. You can bill 51701 for the straight cath, but you cannot bill for G2211, which is not payable when you report the E&M with a modifier 25, except for if the modifier 25 indicates a Part B preventative service, such as a pap smear, immunization, administration, or an annual wellness visit. For example four, a patient presents with complaints of worsening bulging, pressure, and difficulty emptying her bladder. She has a history of stage two prolapse and previously tried pelvic floor exercises with limited relief. The physician performs a history and physical, including a pelvic exam to assess the extent of the prolapse and discusses treatment options. The patient decides she would like a pessary, so the physician performs a fitting. The patient is instructed on pessary care, complications, and follow-up. You can bill an E&M code with modifier 25 to indicate the E&M and service was medically necessary and distinct from the pessary fitting. And you can bill 57160 for the pessary fitting and insertion, but you cannot bill for the G2211, which is not payable when you report the E&M service with modifier 25, again, except for Part B preventative services, immunizations, or annual wellness visits. Here are some resources for the Oggs coding resource community and coding fact sheets. And then also, here's a resource regarding OX coding today. This is essentially, it helps if you have any of your billing questions when you're done with your procedure and you're not 100% sure of if you should code that lephoric copal clysis in addition to elevator myorrhaphy, it will let you know if that is bundled or not bundled and how appropriately to list the one that has the highest RVU and then list down to the lowest RVU so you can reimburse, get the proper reimbursement for you in addition to other information that can help you with the OX coding today. Thank you everyone who has worked with the chat during the time of also the presentation. And so, I believe at this point, we will move to the Q&A. Tashi, is there anything else that we need to take care of as far as housekeeping items before we move on to that? No, we just want a friendly reminder to be sure to post your questions in the Q&A, not in the chat, so that everyone can see the responses from our speakers. And I would say, Jamaica, the only other thing is maybe we start with the three that were submitted or four, I can't remember, in advance. And then we can go into the ones that are in the current chat. Perfect. So, we'll start with the first question that was actually sent to us. We've actually have those questions assigned to certain members in the OX committee. So, we'll start with the first question that was assigned. All right. So, the first question, I work in a private practice at a satellite office location. The nurses do the Eurodynamic studies. Recently, a representative told us that the physician interpreting the UDS needs to be physically in the office space in order to sign the report. The physicians are always available, but not necessarily in the office during the time of UDS. Is this a new rule? What are practices doing with the new possibility of Medicare no longer covering telehealth visits? Is there a way telehealth can still be an option for the appropriate patient? So, for the first part of the question, there was in the slides for appropriate procedures that are at least as documented that are being done by the nurse with the appropriate modifiers, that virtual direct supervision is okay per CMS guidelines. The second is more of, I think, a bigger question for all of us in our practices. What are we doing with the new possibility of Medicare no longer covering telehealth? I'm sure we've all had these conversations with our groups. At this time, there's likely a hold on CMS submitted payments or claims for Medicare telehealth. I have been told internally in my institution that it's likely that these holds will exist, but it's likely that there will be retroactive payment at the time. Yeah, I'm happy to have anyone else weigh in. We're all very hopeful that it will happen. There's ongoing bipartisan support for this. It's just kind of when this will happen. Thank you, Emily. I believe the next question is Jackie. That's right. The question is, if a pessary fitting is performed but all the pessaries are expelled or uncomfortable and the patient does not leave with the pessary in, is it still appropriate to bill for a pessary fitting procedure 57160? My understanding is that it should be billed as the fitting was still performed. I have been billing for the fitting but not billing for the pessary itself. In these cases, but our coders have been removing the fitting code. And the answer to that question is that you can bill for your time and bill time-based E&M, or you can bill for the pessary fitting and just not for the pessary, the actual device. So I had a question about whether anyone is using RTM coding. So RTM is Remote Therapeutic Monitoring Services. And these are services that involve the use of technology to monitor patients' non-physiologic data. So pain levels, therapy adherence, functional status outside the traditional office setting. This is a new and emerging area of medicine in the CPT code set. Currently, there are CPT codes for RTM technologies related to respiratory, musculoskeletal, and cognitive behavioral therapy. There are no specific CPT codes for RTM related to urogynecology or urology. However, the principles of RTM can be applied to various aspects of pelvic floor therapy and rehabilitation. So for example, patients who are undergoing treatment for conditions like urinary incontinence or prolapse can benefit from RTM by receiving tailored exercise programs through digital platforms that monitor adherence and provide feedback with the goal of enhancing the effectiveness of that care. Again, outside of the traditional office setting. So seeing a lot more interest in RTM codings. And while there are no specific RTM codes for urogynecology at this point in time, that is something we might see down the road. Perfect. Thank you, Rachel. And my question that we received from the members who joined the call today previously before the webinar started. When the 64581 code was initially changed to read quote open, I thought we were instructed not to use it any longer unless performing quote traditional cut down. But I recently noticed the OGS guidance document states to continue using it for placement of tied leads in the OR and to use 65461 for placement of P&E leads. So the answer is 64581 is still being used for stage one placement as still making a STAB incision. So in fact, the 2024 fact sheet is still accurate. If anyone has a question of why that decision was made, there was discussion regarding if those codes would actually be reopened and considered for revaluing and when the two leading organizations, OGS and AUA, met, the decision was made not to reopen those codes and to continue to use these older codes that we were using to avoid devaluing the costs of the 64581. And I believe with that, we have a couple of questions in the chat and some of them who have been answered and some who have not been answered. So, Tashi, would you like me to go through them or you and to make sure that all of them have been answered? I think some of the questions that have came up are. You're free to put voice to any of the questions in the chat. Yeah, I think there were a couple of questions about G2211. So, I can provide hopefully a little additional clarity there. So, when G2211 became effective in 2024, the Medicare rule was that you couldn't report G2211 if you were reporting the base E&M code with modifier 25 indicating that there was a separately payable procedure also provided to the same patient on the same date of service. What ended up happening was CMS was getting some feedback from stakeholders that some preventative services such as annual wellness visits or vaccines are often provided on the same day as a separately identifiable E&M visit, but because of the rule that you couldn't report G2211 when modifier 25 is appended to the E&M visit, you couldn't therefore, you know, do a vaccine administration in E&M and G2211. You could do an E&M and G2211 or an E&M and the vaccine administration. And there were concerns about how this might impact access to care. And CMS has also just been very focused in the last several years with ensuring, you know, appropriate reimbursement for primary care services in particular. So in 2025, what they did is they went back and they said, you still can't bill G2211 if you're reporting modifier 25 with the E&M code, except if that separate procedure that you're appending modifier 25 to the E&M code for is a vaccine administration service and annual wellness visit or other preventative services that are covered under Medicare. So again, previous guidance was if you're reporting G2, if you're reporting an E&M with modifier 25, you can't report G2211. New guidance effective 2025 is if you're reporting an E&M with modifier 25 for an annual wellness visit, preventative service, or vaccine administration, you can report G2211. Question from the chat reads, for the transfer of care, typically the bill is submitted at the time of surgery, how are they going to know if the surgeon does not revise their billing? I'm happy to take this one. So obviously, this was one of the chief complaints from stakeholders about this policy is just the additional administrative complexity and potential burden that it could take on practices. Again, the policy is now you will have to apply the transfer of care modifiers, whether or not that transfer of care is formally documented or not formally documented. So again, in the example we discussed earlier, an unexpected transfer of care. So the surgeon does the surgery, isn't expecting to transfer the post-op care, but something happens at some point during that post-op period, and post-op care does get transferred, what does that surgeon do if they've already submitted that claim without the appropriate modifier? This is a big point of contention. CMS hasn't provided any specific guidance, and to the best of my knowledge, none of the Medicare administrative contractors or the fiscal intermediaries that process claims on CMS's behalf have either. We've heard anecdotally that some practices are holding claims or that CMS is not processing those claims. Again, that's just anecdotal. So it's really up to each practice to make sure that they're being really vigilant about that, to make sure that they are receiving payment for the services provided. And this will, I'm sure, be something that CMS addresses in future rulemaking as more claims data becomes available and they can see how the new policy is impacting use of these modifiers. We're just reviewing through the online questions to make sure that they've all been answered. There was a question earlier about whether the decrease in the conversion factor that we talked about at the top of the presentation was for urogynecologists only or OBGYNs only. Conversion factor cut applies to all physicians. The conversion factor is a standardized dollar amount that is used to convert relative value units into a payment amount and that conversion factor is the same for all physicians irrespective of their specialty. The last thing I'll add on that is because I think we had a note that this previous weekend the House came to an agreement on a continuing resolution that passed out of the House yesterday afternoon on March 11th and now goes to the Senate. Very notable that that continuing resolution does not provide a fix to the conversion factor cut for 2025. As Dr. Price noted at the top of the presentation this is the fifth straight year in a row of cuts to the conversion factor and in every previous year Congress has acted to either partially or fully mitigate the conversion factor cut including last year. They weren't able to do that before January 1 so the cut went into effect but then they were able to provide a legislative fix at some point in I think February or March and then they retroactively applied that to claims submitted from January 1 until that point. That hasn't happened this year. As I mentioned the continuing resolution that passed out of the House this yesterday does not include a conversion factor fix. Republican leadership has signaled that they would not support any package that didn't include a conversion factor fix particularly among the GOP's Doctors Caucus. So it remains to be seen if the package is going to move forward as is without that. It looks like it likely will so that would be the first year in five years that there has been both a conversion factor or there has been a conversion factor fix with a conversion factor cut with no fix from Congress. Perfect and I think what we'll do with the ones who are open since those seem like the main themes that we've answered we'll try our best to go through these questions if some of them are repeats then I won't repeat the question we'll start with the one that's right at the top at 6 40 for the for the open. Just to respond to this you can bill for telehealth visit but use the old E&M new established codes with modifier 95 if audio-visual can also include G-2211. If I use the old codes will they be paid or on hold until until retrospective payment? Rachel do you want to take that one? Yeah so if you're if by the old codes you're referring to 99441 through 443 the telephone only E&M codes those were deleted from the CPT code set effective January 1 2025. So you don't want to use those what you do want to use is the office outpatient E&M code so 99202 to 205 and 99212 to 215 and then with those codes you want to append the appropriate modifier so I believe it's I might reverse it it's 93 and 95 one is for audio-visual and one is for audio only and then G-2211 is on the list of Medicare telehealth services so you could also report G-2211 with the office outpatient E&M code when provided via telehealth and appended with the appropriate telehealth modifier. Thank you. The next set of the three questions are from Dr. Showberry regarding what constitutes being immediately available in the office when Eurodynamics are performed. Let's see anyone on the on the panel want to tackle this one? Yeah so this is again another policy that was put in place during the COVID-19 public health emergency and has been extended since but according to CMS they consider immediate availability through virtual present using two-way real-time audio-visual technology so it's that immediate availability through a virtual technology as opposed to in person. The next one is by Dr. Mzadi and the 99459 code is dependent on whether your clinic is licensed or non-licensed best to check with your billing department so just to remind you again the public exam code it's an add-on g-code that actually is used when you are in the non-facility identified practice so if your facility is actually hospital owned you are not considered a non-facility practice so again if that if you do not know that then you can always check with your billing manager and they will definitely be able to give you that answer. Next is why did by Dr. Park why did OB-GYN get a negative one percent decrease and urology a zero percent decrease? Yeah I can take this one so the way the specialty impacts they're a little confusing and it's basically an aggregate so what CMS does is they look at all of the services that are reported by specialty type so urology or OB-GYN in this instance and then they look at what the changes in RVUs for those services are from 2024 to 2025 and they volume adjust that based on the relative volume of those services based on previous year's claims data and that's how they calculate the specialty impact so obviously for any individual practice the impact of changes in Medicare payments is going to vary based on the specific mix of services that you are providing. CMS's impacts are just based on what they say in claims data as the codes being reported with the specialty code so to this specific question we would need to look you know at a more granular level of you know what are the codes being reported by OB-GYN versus the codes being reported by Euro and then how are those changing from 2024 to 2025 and that gives you a sense of what's driving those changes and specialty impacts but again that's like a very high level CMS is looking at all services built the impact on any given practitioner or practice is going to vary based on the specific mix of services that you're reporting. Thank you Rachel. The next question do you use SystoPak in addition to SystoCPT 5200? So again just remember that when you are billing for example when you are billing for like a pessary you're billing for the pessary fitting and insertion in addition to if you are providing the pessary from your clinic you are charging that pessary code for the device similar with Systo. I hope that makes sense. Okay I will move to the next one. It looks like Dr. Thompson Doug is answering this question for those who asked when billing for a copeplexis can you also bill for an interior posterior coporaphy? So I will move past that one. The next one is with copepexi can you bill for insertion of mesh times two? Anyone on the committee panel that would like to answer that? It looks like Doug is typing an answer. I don't know if you just want to answer that verbally Doug. Oh never mind he's typing. I'm sorry I would have to look that one up. I'm sorry you're typing the first one. I believe that the mesh is included in the description and therefore if it's included in the description you cannot charge for it. Yeah I think that's right. I think the 57425 is supposed to specify the use is supposed to basically infer the use of mesh and so you wouldn't be able to then also charge for the insertion of mesh on top of that. I think that's right. Yes that is correct which is the reason why if you're doing for example a robotic utero sacral you would not be able to use the 57425 because that CPT code actually describes an insertion of a graph that is attached to the vagina. The next question is any suggestions on getting a 58262 hysterectomy and a 57283 utero suspension to not bundle? A 59 modifier does not seem to work with such insurances such as UnitedHealthcare and Aetna. All I can say is dealing with UnitedHealthcare and Aetna is very difficult and their rules are often very different than what CMS's rules may be and they have bundled those codes and and they're allowed to unfortunately. Yes I agree with that statement too. Unfortunately you can always when you're billing it to make sure that you are describing in your operative note a very separate and distinct description of your utero sacral suspension but at the same time if they are not acknowledging that as something that is not bundled even though CMS has agreed that that does not have to be bundled then they have a right to as a private insurance. The next question is anonymous. Could you clarify the use of 56810? You mentioned it cannot be billed with interior repair but then state it can be used with any repair code. I believe they are, Doug, I think they're asking that regarding an answer that was given. Well, you know, 568, the question had to do with peroneoplasty and that's what 56810 is. That particular code cannot be used with another repair code. They are just incompatible. So, the original question was, can I use an anterior repair code with the peroneoplasty? And the answer is no. And therefore, I recommended that if you use the code 57240, I believe that's correct, with an anterior repair, that would be an anterior and posterior repair, and that would cover both of those. But the peroneoraphy code does not work with the repair code. Now, another question came across, and I wanted to answer no, but I got to share this with you, because I was looking it up on Oggs today, Oggs coding today, and it really surprised me. The question was, can I code an anterior and posterior repair, which is 57240, along with a culpal clysis, which is 57210? Well, normally, I would say no to that, because it seems like it's included. However, Oggs coding today says it's okay to build. I'm very surprised by that answer. With that being said, I am on behalf of Oggs, I'd like to thank the coding committee and the live speakers for this informative webinar. The PowerPoint and recording will be made available to all registrants before the end of the week. All registrants will be notified via email when it is available. Follow Oggs on Twitter and Instagram, or check out our website for information on all upcoming webinars. Thank you for joining us this evening. Have a wonderful night. Thank you, everyone.

medical coding

physician reimbursements

CPT codes

telehealth

reimbursement reduction

urogynecology

G2211 add-on code

specialty impacts

care transfer policies