12. CONTINUING EDUCATION & PRACTICE MANAGEMENT

• Sleep • Exercise, such as running, yoga, etc. • Movie nights or dinners • Holiday potlucks • Ballroom or other dance classes that include spouses and significant others • Charity work (e.g., volunteering at a homeless shelter) • Mindfulness and meditation classes to promote stress reduction • Sporting events (e.g., playing in a recreational league, watching a televised match or attending a university game) • Painting or pottery classes • Exploring the local culture

11.5 Resources

• Mayo Clinic's 5-Pillar Anti-Burnout Remedy www.urologytimes.com/editors-choice-ut/beyondburnout-how-stay-engaged-and-thriving • Stanford Medicine WellMD Center (first of its kind) http://wellmd.stanford.edu/healthy/stress.html • American Medical Association https://www.ama-assn.org • www.STEPSForward.org • www.jeffsmithmd.com • www.TheHappyMD.com

WATCH: Amanda North, MD, Hadley Wood, MD, and Deborah Lighter, MD, discuss wellness and burnout as part of the AUA2019 Residents Forum program. 12. CONTINUING EDUCATION & PRACTICE MANAGEMENT

12.1 Certification

The following text is from the American Board of Urology (ABU) website as of May 2021. For more information, please visit www.abu.org/certification. The purpose of awarding certification to individuals who meet the qualifications of The American Board of Urology is to assure the public that an individual has: (a) received appropriate training, and (b) has a level of urologic knowledge to practice safe and effective urology. The American Board of Urology strives to provide the urologic community with an examination process which is relevant and fair to all who take it. Certification includes all domains of urology, including but not limited to pediatric urology, endourology, female urology, andrology, oncology, and general urology. All certified urologists are trained to evaluate and treat all patients with urological disorders. All US chief residents who have completed their training and residency requirements may apply for admission to the certification process. Canadian and international medical graduates may be eligible to apply if they have satisfied the training and residency requirements. Applicants approved by the Board to enter the certification process must successfully complete a Qualifying (Part 1) Examination. After meeting certain specific criteria including unrestricted medical licensure, assessment of clinical practice through practice logs, acceptable peer review, and the 16-month practice requirement in a single community, the applicant must successfully complete the oral Certifying (Part 2) Examination to become certified. Certification is valid for a period of ten years, subject to Lifelong Learning (LLL). Candidates have six years from the end of residency to complete the components of the certification process to become a Diplomate. An applicant will have no more than three attempts to pass the Qualifying (Part 1) Examination and no more than three attempts to pass the Certifying (Part 2) Examination. If a candidate fails the Qualifying Exam for the third time the Board may consider individual requests to re-enter the process. These requests will be assessed on a case-by-case basis. The applicant will be required to undergo a professional competency and/or educational assessment in a program approved by the ABU. If a candidate fails the Certifying Exam for the third time or fails to pass the exam within the required window of six years from residency (with any approved variances), the Board may consider individual requests to reenter the process. The applicant will be required to undergo a professional competency and/or educational assessment in a program approved by the ABU. For either exam, evaluations will be performed at the expense of the candidate. Specific CME activity or other evaluation may also be assigned. If re-entry criteria are met, the applicant will be

allowed to apply to re-take the exam. Approved re-entry applicants for either exam will generally be expected to take the exam at the next available time it is administered. Failure to do so requires a written excused absence from the ABU, and only one such excused absence will be allowed. The candidate will be expected to successfully complete the entire process (QE and CE) within four years from reentry.

12.2 Lifelong Learning

The following text is from the American Board of Urology website as of May 2021. For more information, please visit www.abu.org/learning/faq. Maintenance of Certification (MOC) was an initiative of the American Board of Medical Specialties (ABMS) aimed at ensuring quality patient care from certified physician specialists through an ongoing process of professional self-improvement. A ten year cycle, MOC entailed four levels and these basic components: licensure and peer review; continuing medical education; practice log, Practice Assessment Protocols (PAP), and modules for patient safety and professionalism/ethics; and a computerized, multiple choice exam Completion of these components allowed Diplomates of the ABU to maintain their general certification in urology and any urologic subspecialty certification. Responding to Diplomate feedback, in 2017, the ABU dismantled its MOC program and created, instead, the Lifelong Learning program as a certification requirement. Lifelong Learning (LLL) is a 2017 initiative of the American Board of Urology aimed at ensuring quality patient care from its certified urologists through an ongoing process of professional selfimprovement. It is a retooled version of the former Maintenance of Certification (MOC) program. A ten year cycle, LLL is comprised of two Levels and these basic components: licensure and peer review; continuing medical education; practice log, Practice Assessment Protocols (PAP), modules for patient safety and professionalism/ethics, videos for patient safety; and a computerized, multiple choice knowledge assessment. Completion of these components allows Diplomates of the ABU to maintain their general certification in urology and any urologic subspecialty certification.

12.3 Medical Coding and Billing

Staying current on key coding issues, particularly as they relate to the yearly changes from Current Procedural Terminology (CPT®) is important. Using outdated books can lead to unnecessary denials or may result in delayed reimbursement. CPT codes are updated annually, and are effective for use on January 1 of each year. New and Revised CPT Codes for Urology Effective January 1, 2021 There are a number of CPT code changes that urologists should understand that became effective as of January 1, 2021, including changes to Evaluation and Management (E/M) and Telehealth coding. Revision Under Evaluation and Management Effective January 1, 2021, the Centers for Medicare & Medicaid (CMS) finalized significant changes to the office and outpatient E/M services (CPT codes 9920299215) for both new and established patients. Specifically, CMS increased the valuations for the majority of these services; developed new documentation requirements that allow providers to bill by time or medical decision making; and created a new add-on code for prolonged time on the day of service, HCPCS Code G2212 (for Medicare patients)/ CPT code 99417.

Increased valuations for outpatient E/M services (CPT codes 99202-99215)

Some E/M services have increased in value due to updates to the Relative Value Units (RVUs).

New add on code to be billed for prolonged time

HCPCS code G2212 can only be reported when the time of the physician or qualified healthcare professional is used to select the visit level. Bill this code only when the maximum time level 5 visit is exceeded by at least 15 minutes on the date of service and then for each subsequent 15-minute interval. This code will be used for

Medicare billings as opposed to CPT code 99417.

Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service: each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT code 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416) (Do not report G2212 for any time unit less than 15 minutes).

Elimination of CPT code 99201 The CPT Editorial Panel deleted 99201 (new patient, Level 1). This code can no longer be billed. Removal of history and exam criteria used to select the level of E/M service History and exam are no longer used to select an E/M service, but still must be performed in order to report CPT codes 99202-99215. New documentation requirements that allow providers to bill by time or Medical Decision MakingMDM (MDM) E/M code selection can be based on either: 1. The time performing the service on the day of the encounter; or 2. The level of MDM Time Office/outpatient E/M services can be documented based on face-to-face and non-faceto-face time spent on patient care on the date of service.

New Patient E/M Services

99202 15-29 Minutes 99203 30-44 Minutes 99204 45-59 Minutes 99205* 60-74 Minutes

Established Patient E/M Services

99212 10-19 Minutes 99213 20-29 Minutes 99214 30-39 Minutes 99215* 40-54 Minutes

* Additional time may be reported with CPT code G2212, prolonged office visit, for each 15 minutes beyond the upper limit for CPT codes 99205 and 99215

Medical Decision Making In order to select a level of E/M service, two of the following three elements must be met or exceeded for the visit level: 1. The number and complexity of problems addressed; 2. Amount and/or complexity of data to be reviewed and analyzed; and 3. Risk of complications and/or morbidity or mortality of patient management. Payment for office/outpatient E/M services

CPT Code Total NonFacility RVUs Payment

99201 DELETED CODE

99202 2.13 99203 3.28 99204 4.98 99205 6.51 99211 0.68 99212 1.67 99213 2.68 99214 3.81 99215 5.33 G2212* 0.97 $74.32 $114.45 $172.02 $227.15 $23.73 $58.27 $93.51 $132.94 $185.98 $33.85

NOTE: In the CY 2020 Medicare Physician Fee Schedule (PFS) final rule, CMS finalized an add-on code to be billed for complexity HCPCS code G2211. On December 27, 2020 Congress enacted the Consolidated Appropriations Act, 2021, which included several provisions that would result in increases in Medicare payments for physicians and other health professionals. As a result, the law provides for a 3-year moratorium on payment under the PFS for HCPCS code G2211, thereby delaying implementation of this code until CY 2024.

12.4 Telehealth Codes

Telehealth, sometimes referred to as telemedicine, is the use of electronic information and telecommunications technologies to extend care when you and the patient aren’t in the same place at the same time. Technologies for telehealth include videoconferencing, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Telehealth services may be billed and paid differently, depending on the payer/insurer you are working with and your geographic location.

Types of Telehealth • Live video – also referred to as “real-time;” a two-way, face-to-face interaction between a patient and a provider using audiovisual communications technology • Store-and-forward – remote evaluation of recorded video and/or images submitted by an established patient • E-visits – non-face-to-face patient-initiated communications through an online patient portal • Remote patient monitoring – use of digital technologies to collect health data from patients in one location and electronically transmit that information securely to

providers in a different location (data can include vital signs, weight, blood pressure, blood sugar, pacemaker information, etc.) • Audio-only visits – use of telephone for visits without video • Mobile health (mHealth) – allows patients to review their personal health data via mobile devices, such as cell phones and tablet computers, which can be done from their home and assists in communicating their health status and any changes; often includes use of dedicated application software (apps), which are downloaded onto devices • Case-based teleconferencing – Method of providing holistic, coordinated and integrated services across providers; usually interdisciplinary, with one or multiple internal and external providers and, if possible and appropriate, the client and family members/close supports Billing for Telehealth Billing and reimbursement requirements for telehealth services vary among different payers/ insurers and for different geographic locations. Factors include: • Federal policies and regulations, including

Medicare • State policies and regulations, including Medicaid and commercial insurers Current policies, regulations, and requirements are evolving and subject to change: • Many are temporary and in effect only during the

COVID-19 Public Health Emergency (PHE). • Some changes in response to the PHE may be extended or become permanent. • If you are unsure about coverage or have questions about particular plans, your staff may wish to contact the insurance carrier to verify what types of telehealth are covered and if the telehealth service your patient requires is a covered benefit. Federal Policies: Medicare The federal government announced a series of policy changes (https://telehealth.hhs.gov/providers/policychanges-during-the-covid-19-public-health-emergency) that broaden Medicare coverage and payment for telehealth services during the COVID-19 PHE. The following are important resources to learn more about billing, coverage, and payment, as well as the latest updates on the PHE, waivers and flexibilities, and final rules: • Billing and Reimbursement https://telehealth.hhs.gov/providers/billing-and-re imbursement/?section=1,2,4#billing-medicarefor-fee-for-service-telehealth • HIPAA Flexibility for Telehealth Technology https://telehealth.hhs.gov/providers/policychanges-during-the-covid-19-public-healthemergency/hipaa-flexibility-for-telehealthtechnology • OIG Cost-Sharing Waiver Policy Statement https://oig.hhs.gov/fraud/docs/ alertsandbulletins/2020/policy-telehealth-2020. pdf • Medicare Telemedicine Fact Sheet https://www.cms.gov/newsroom/fact-sheets/ medicare-telemedicine-health-care-provider-factsheet • Medicare Telehealth FAQs https://www.cms.gov/files/document/medicaretelehealth-frequently-asked-questions-faqs-31720. pdf • List of Medicare Telehealth Services https://www.cms.gov/Medicare/Medicare-

General-Information/Telehealth/Telehealth-

Codes • Medicare Fee-For-Service Response to the PHE on the COVID-19 https://www.cms.gov/files/document/se20011.pdf • CMS COVID-19 Updates https://www.cms.gov/About-CMS/Agency-

Information/Emergency/EPRO/Current-

Emergencies/Current-Emergencies-page Medicare policies in place during the COVID-19 PHE (https://www.phe.gov/emergency/news/ healthactions/phe/Pages/covid19-2Oct2020.aspx) expand payment for telehealth. Using emergency authorities enacted by Congress for the PHE, CMS announced a number of temporary waivers of statutory telehealth payment requirements. CMS also issued an array of temporary regulatory flexibilities for Medicare telehealth services during the COVID-19 PHE.