 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, in Towson, Maryland.

Jonathan Rubenstein, MD

Jonathan Rubenstein, MD (shown here), and Mark Painter write, "There are 4 

When billing Principal Care Management (PCM) codes, what is the appropriate billing when a patient’s care is split between 2 providers from different specialties? An example would be a patient with advanced prostate or bladder cancer, with the urologist monitoring urinary issues and a medical oncologist monitoring chemotherapy-related issues, but both working for the same hospital or organization. Who would bill and get credit for the PCM code?

Mark Painter (shown here) and Jonathan Rubenstein, MD, write, "Based on the diagnosis of advanced prostate cancer or bladder cancer, it is possible that your urologist has developed the plan of care that includes chemotherapy as the primary care provider for the disease state."

PCM codes were created because specialty care practitioners often treat patients with a single high-risk disease and do not meet criteria for reporting other types of care services requiring management of multiple conditions. A serious, chronic condition is defined by a patient having a diagnosis that is expected to last at least 3 months to a year or until death and that:

• May have led to recent hospitalization or has significant potential to do so,

• Places patient at significant risk of death, or

• Must be actively managed to prevent acute exacerbation, decompensation, or functional decline

PCM codes require the practitioner to develop a disease-specific care plan, to obtain a patient’s verbal or written consent, and to educate the patient on PCM. Patients require uninterrupted (24 h/d, 7 d/wk) access to a dedicated care team member. A minimum of 30 min/mo is needed to submit a claim for reimbursement.

 codes associated with PCM, based upon the first 30 minutes vs additional 30 minutes per calendar month of care, and based upon the work being performed by a physician or other qualified health care professional who can bill for such services or by clinical staff. The codes are as follows:

• 99424 (Principal care management services, for a single high-risk disease, with the following required elements: 1 complex chronic condition expected to last at least 3 months and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death; the condition requires development, monitoring, or revision of disease-specific care plan; the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional per calendar month)

• 99425 (Principal care management services, for a single high-risk disease… each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month [list separately in addition to code for primary procedure])

• 99426 (Principal care management services, for a single high-risk disease… first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)

• 99427 (Principal care management services, for a single high-risk disease... each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month [list separately in addition to code for primary procedure])

The case described above states that the urologist is following the patient for urinary issues whereas the oncologist is monitoring chemotherapy-related issues. Even when it comes to monitoring patients for chemotherapy, it is important that one meets these criteria. Based on your question, it seems that the PCM would be of the patient’s cancer, with urinary and chemotherapy possibly being part of the care plan.

Based on the diagnosis of advanced prostate cancer or bladder cancer, it is possible that your urologist has developed the plan of care that includes chemotherapy as the primary care provider for the disease state. As noted in the description, the billing physician must be the one who provides the development, monitoring, and revision of the care plan and is responsible for adjustment of care either directly or through coordination with other health care professionals. Documentation will need to support these aspects of the services provided, including any coordination of care.

If, on the other hand, it is possible that the primary care of the prostate or bladder cancer is primarily under the oncologist due to the disease state, it may be more appropriate for the oncologist to be the primary manager of the disease state even though your urologist did so previously.

One person should be designated the primary caretaker of the patient’s cancer and underlying disease, and whomever is specifically responsible for overall care of the patient should report the codes. Reporting of these services should be coordinated between the physicians.

Articles

"PCM codes require the practitioner to develop a disease-specific care plan, to obtain a patient’s verbal or written consent, and to educate the patient on PCM," write Jonathan Rubenstein, MD, and Mark Painter.

How to bill Principal Care Management codes when 2 specialists are involved

Jonathan Rubenstein, MD (shown here), and Mark Painter write, "The conversion factor for 2023 is set to decrease by approximately 4.5%, from $34.6026 to $33.06." 

On November 2, 2022, the Centers for Medicare & Medicaid Services (CMS) released the 

calendar year 2023 Medicare Physician Fee Schedule Final Rule

. This final rule outlines the updates for payment and policies for providing care to Medicare beneficiaries starting January 1, 2023. Most of the rules that were included in the proposed rule from July 2022 were adopted, with a few exceptions. Here are some of the most notable rules that affect those who practice urology.

 The conversion factor for 2023 is set to decrease by approximately 4.5%, from $34.6026 to $33.06. The decrease is mainly due to the expiration of a 1-year 3% increase that was enacted at the end of 2021 as part of the Protecting Medicare and American Farmers from Sequester Cuts Act, coupled with a mandated 0% increase and a reduction due to budget neutrality.

Mark Painter (shown here) and Jonathan Rubenstein, MD, write, "Given today’s inflation, staff shortages, and other overhead expense increases, the outlook is not a happy one."

We remain hopeful that Congress will once again step in to mitigate this decrease between now and the end of 2022. If that is to happen, it will likely be near the end of December. This cut affects not just urology, but all of organized medicine. Stay tuned.

 With minor revisions from the proposal, CMS is changing the update process for clinical labor included in the calculation of the practice expense component within the Medicare Physician Fee Schedule. We are in the second year of this change. Medicare has indicated that it will continue to examine the process it uses to increase the transparency and consistency of this update. Additionally, Medicare is updating the malpractice component of the fee schedule as well. Urology is projected to face a 1% decrease overall in Medicare RVU changes related in large part to these changes, the impact is slightly greater in the office-based payments. The impact to group practices and individual physicians, however, varies based on practice type, mix of patients, and services provided to those patients.

 Note: The impact of relative value unit (RVU) changes is independent of the conversion factor change noted above

Evaluation and management (E/M) services: revisions for outpatient consultation and hospital inpatient and observations services, effective January 1, 2023.

 As proposed, CMS will adopt nearly all the updates and revisions for Current Procedural Terminology (CPT) codes used to report E/M visits. For urologists, this includes outpatient consultation services and hospital-based inpatient and observation services. The changes include revisions to the documentation guidelines and to the descriptors, which will mirror the revisions previously made to the Office and Other Outpatient E/M services in 2021.

As noted in our article about the proposed rule,

 these updated E/M codes will now follow the same basic structure as the updated 2021 Office or Other Outpatient E/M code guidelines. These updates include requiring the history and physical examination to be medically appropriate but are not used to determine code level. Ultimately, the E/M code level should be chosen based on either minimum total time or by medical decision-making. If choosing a coding level based upon medical decision-making, the updated chart is used.

Additionally, hospital E/M coding is changing as inpatient E/M codes and observation E/M codes have been combined into 1 code set, maintaining the same codes that had previously been used to report inpatient services, whereas the outpatient codes will be eliminated. Therefore, there will be just 1 code set to report consultation services, initial services, subsequent services, discharge, and same-day admit/discharge services. This made sense as the work and payment were already similar between these 2 code sets, but having 2 separate code sets led to code choice confusion.

CMS appears to have deviated from the guidelines and coding in the 2023 E/M guidelines in only a few areas:

1. CMS finalized their proposed 1-year delay (until 2024) of the updated split/shared services policy where the billing provide is determined by which qualified health professional spends the most time with the patient on the date of service.

2. CMS has elected to keep the current rules requiring that a physician that bills an Initial Inpatient code include all E/M services provided on that date. (New for CPT 2023: CPT guidelines allow for reporting more than 1 E/M service on the same date as an Initial Inpatient code.)

3. As with Office and Other Outpatient services, CMS will require the use of a Healthcare Common Procedure Coding System code (G0316 definition below) in place of the CPT prolonged service code created for the new Inpatient codes 99418 (prolonged inpatient or observation evaluation and management service[s] time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time). [List separately in addition to the code of the inpatient and observation E/M service.]

HCPCS Code G0316(prolonged hospital inpatient or observation care evaluation and management service[s] beyond the total time for the primary service [when the primary service has been selected using time on the date of the primary service]; each additional 15 minutes by the physician or qualified health care professional, with or without direct patient contact [list separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services]. [Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99415, 99416, 99418]. [Do not report G0316 for any time unit less than 15 minutes].

Based on the definitional changes for Inpatient E/M codes, CMS revalued the code series. 

 The final rule resulted in slight changes from the work RVU impact in the proposed rule. The 

includes the codes in urology with changes greater than a 5% increase or decrease in work RVU.

 CPT codes 50080 and 50081 are undergoing a description change that has resulted in the changes shown in in the Table. Code 55867 is a new CPT code for laparoscopic simple prostatectomy, which has affected the value of the other prostatectomy codes listed in the Table.

Medicare has finalized its planned compliance with the Consolidated Appropriations Act (CCA), CMS originally announced that it would comply with the act in March 2022. This final rule codifies is approach to compliance with the act. The CCA directs CMS to extend the public health emergency (PHE) rules allowing telehealth and telephone services be provided to Medicare patients regardless of patient location for 151 days after the COVID-19 PHE expires. As of the writing of this article, the Senate has yet to address the House bill intended to extend PHE rule for telehealth through 2024; we will continue to watch this proposed law and others. Based on the success of telehealth from the perspective of patients and physicians, it would appear there is support for long-term continuation and expansion of telehealth for Medicare.

Requiring manufacturers of certain single-dose container or single-use package drugs to provide refunds with respect to discarded amounts

Medicare has published its list of 25 drugs that will be subject to the proposed policy requiring manufacturers to provide a refund to CMS for certain discarded amounts from a single-dose container or single-use package drug. The refund amount is the amount of discarded drug that exceeds an applicable percentage, which is required to be at least 10% of total allowed charges for the drug in a given calendar quarter. As reviewed, it appears that 1 drug on this list that urologists use with regularity is collagenase clostridium histolyticum (Xiaflex). CMS has indicated that other drugs will likely be added to the list in the future.

In the proposed rule, CMS considered whether to use the authority granted by Congress to raise the applicable percentage of waste that triggers a refund for drugs with unique circumstances. Specifically, the agency considered drugs that must be reconstituted with hydrogel, noting that a substantial amount adheres to the vial wall during preparation. The agency speculated 35% may be appropriate to account for the portion of the drug that adheres to the vial. The American Urological Association commented that CMS should use its authority and finalize policy that raises the applicable percentage to 35% for wastage associated with drugs reconstituted with hydrogel. With this rule, CMS has finalized its proposal to allow for a special dispensation for 35% wastage for drugs of this type, this special dispensation will apply to only 1 drug : mitomycin for pyelocalyceal solution (Jelmyto).

This rule does not change reimbursements or change reporting requirements for physicians.

Final rule for Outpatient Perspective Payment System (OPPS) changes

The final CMS calendar year 2023 OPPS rule increases payment rates for code C9769 covering the iTind procedure in hospital outpatient department (HOPD) and ambulatory surgical center (ASC) facilities. The rule changes are as follows. In the HOPD: CMS reclassified the urology ambulatory payment from a level 5 to a level 6 and finalized a national average payment rate of $8221.74 per procedure in OPPS payments. In the ASC: CMS finalized a national average payment rate of $7274.78 per procedure in ASC payments.

High-intensity focused ultrasound (HIFU).

 For a hospital performing a HIFU prostate ablation on an outpatient basis, the final rule increases the reimbursement level to an ambulatory payment classification level 6, as compared with APC level 5 currently. This will increase reimbursement to a hospital performing a HIFU procedure on a Medicare patient to $8557.53 per procedure in the HOPD and $4280.98 in the ASC.

The final rule is not the only federal budget action that is slated to impact physician payment. The act referred to as the Pay As You Go rule (also known as PAYGO) has been triggered due to US Department of Health and Human Services spending beyond its targeted budget for multiple years.

In a widely oversimplified explanation, the PAYGO Act mandates that a 4% budget adjustment be applied to all CMS expenditures. This adjustment, unless Congress once again delays its implementation, will result in second sequestration type rebate of 4% for all services paid for by CMS, including Part A, Part B, Part C, and Part D Medicare. The 4% deduction will applied to drugs, physician services, facility payments to hospitals and ASCs, and prescription drug reimbursements.

Although the general changes in the physician fee schedule outside of the budget-mandated decreases are of minimal impact, we are once again are at the mercy of Congress to help avert what in total amounts to a –9.5% cut to Medicare payments to Urologists for professional services and an additional 4% reduction in reimbursement for buy and bill drugs. Given today’s inflation, staff shortages, and other overhead expense increases, the outlook is not a happy one.

We are slightly encouraged by the strength of the lobbying efforts for physicians to avoid the conversion factor cut, and we welcome the hospitals and insurance company lobbying efforts to avoid the PAYGO budget adjustment impact. We remain hopeful that we will once again cheer a minimal change in overall Medicare payments for 2023 but encourage all to help in these lobbying efforts.

We once again note that even success in the efforts to avoid any payment decreases will be a failure in the long run as overhead continues to rise against flat reimbursement. In the face of physician burnout, the Medicare formula is slowly squeezing urology practice net revenue to $0. The model is not sustainable. We encourage all of you to work smarter and lobby harder.

1. Rubenstein J, Painter M. What’s in the Medicare Physician Fee Schedule proposed rule? 

®. August 11, 2022. Accessed November 18, 2022. https://www.urologytimes.com/view/what-s-in-the-medicare-physician-fee-schedule-proposed-rule-

"We once again note that even success in the efforts to avoid any payment decreases will be a failure in the long run as overhead continues to rise against flat reimbursement," write Jonathan Rubenstein, MD, and Mark Painter.

Breaking down the CMS 2023 final rule for urologists

Jonathan Rubenstein, MD, is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, Towson, Maryland.

Q. I have been asked to return money because of the use of multiplex polymerase chain reaction (PCR) urine cultures for patients. For each patient, I believe the PCR test ordered was medically necessary, and there were no rules at the time regarding the use of PCR. Can you help?

 We have heard of this happening to several medical providers, and it can be a challenge. Let’s start at the beginning. The multiplex (or quantitative) 

Mark Painter is CEO of PRS Urology SC in Denver, Colorado.

PCR test has a broad application for pathogen identification in individuals with respiratory, gastrointestinal, urinary, blood, and neurologic infections, with potential for many other applications. Focusing on PCR testing for urinary tract infections (UTIs), studies have compared PCR tests with standard urine cultures. These studies have indicated that:

PCR tests can detect bacteria that may not be able to be grown on typical agar.

PCR results are often available in less than 24 hours compared with a few days for traditional culture results.

PCR tests may be superior in some respects to typical urine cultures for detecting and identifying of bacteria.

PCR tests detected bacteria in 36% of symptomatic patients who had a negative urine culture result.

PCR tests detected more polymicrobial infections than urine cultures detected (20% of patients compared with 7% of patients).

Although Medicare has developed previous coverage directives for several types of PCR tests outside of UTI detection and there are sound arguments for the use of PCR tests in detecting UTIs, Medicare only recently published a local coverage determination (LCD) that included the use of PCR tests for UTI detection. This policy became effective June 2, 2022, requiring any PCR test set that targets more than 1 pathogen to be defined as a panel. The PCR test set is subject to LCD L39001, which is titled MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing. Furthermore, a test panel that includes more than 5 pathogens and does not have FDA approval as a panel would require application to the MolDx program for a specific panel code.

This policy has only been adopted by half the Medicare administrative contractors (MACs), and the LCD and associated local coverage article provide limited guidance as to when these tests should be used and when they will be covered. The policy requirements have created a different set of administrative issues for billing of PCR tests for UTIs in states where the MAC has adopted the LCD.

For your question, we will focus on the lack of guidance issued in the LCD or elsewhere for PCR testing in relation to UTIs. We will start with general Medicare policy as it relates to services provided with a lack of specific guidance for appropriate use, in accordance with the Medicare Program Integrity Manual (PIM)

This section applies to MACs, CERT [comprehensive error rate testing], Recovery Auditors, and UPICs [united program integrity contractors], as indicated. CMS [Centers for Medicare & Medicaid Services] issues national coverage determinations (NCDs) that specify whether certain items, services, procedures or technologies are reasonable and necessary under §1862(a) (1) (A) of the Act. 

In the absence of an NCD, Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors, and UPICs shall consider an item or service to be reasonable and necessary if the item or service meets the following criteria

It is not experimental or investigational; and

It is appropriate, including the duration and frequency in terms of whether the service or item is:

Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary’s condition or to improve the function of a malformed body member;

Furnished in a setting appropriate to the beneficiary’s medical needs and condition;

Ordered and furnished by qualified personnel; and

One that meets, but does not exceed, the beneficiary’s medical need.

Medical necessity is defined under Title XVIII of the Social Security Act

: “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” The Medicare statute requires that any rule or other statement of policy (other than a material coverage decision) establishing or changing a substantive legal standard must be promulgated by regulation

The terms “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer‐reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment. Unless the contrary is specified, the term “medical necessity” must refer to what is medically necessary 

 and hence entails an individual assessment rather than a general determination of what works in the ordinary case. But where, as here, the plan administrator presents sufficient evidence to show that a treatment is not medically necessary in the 

 case, it is up to the patient and his or her physician to show that 

 individual patient is different from the usual in ways that make the treatment medically necessary for 

These citations constitute a legal doctrine by which evidence-based clinical standards are used to determine whether a treatment or procedure is reasonable, necessary, and/or appropriate. The definitions cited further clarify those legal citations. The answer to your question comes back to whether your care of a single patient and the services you provide to your patients more broadly represent a pattern of care that complies with medical necessity as defined under Title XVIII of the Social Security Act.

As noted, we have some guidance through peer-reviewed medical articles that support the use of PCR testing for the treatment of patients with UTIs. A practice must implement the guidance and data from these peer-reviewed articles for each patient it cares for. Additionally, chart documentation and practice policies need to demonstrate the medical necessity of the service for each case.

If Medicare or another payer has reviewed your records and found they lack support for medical necessity, you have several options to refute them, assuming you have provided appropriate medical care according to the definitions above. You are allowed to develop an appeal and provide to the payer a clear, medically based argument that supports the services you have provided.

In addition to the arguments surrounding medical necessity, you have the right to demand the credentials of the party who has determined the services provided were not medically necessary. Developing an appropriate appeal for these types of takebacks requires careful consideration and attention to detail; in short, they require a plan and the dedication of resources to respond appropriately. You may wish to seek assistance from an organization that specializes in appeals if you are left with any questions.

To assist you and others in developing processes and procedures moving forward, we recommend that each practice using PCR testing develop a guideline or list of appropriate-use criteria agreed upon by your group after review of existing medical literature and discussion. You will the need to educate your professional clinic staff on what these guidelines are, how they should be implemented, and importantly, how to support the use of these tests for each patient.

Below is a sample set of indications for medically necessary and appropriate use of PCR for UTIs that represents a combination of policies developed by different groups:

Refractory UTI: failed standard therapy from urine culture/traditional empiric treatment

Patients sent to urology for recurrent or refractory UTI

PCR test allows identification of specific organisms and resistance genes

Repeat PCR test after treatment in symptomatic patients allows evaluation of treatment and tailoring to sterilize the urine

Complicated UTI: male, fever, foreign body, stone, obstruction, etc

Need for prompt, specific treatment due to risk

Empiric antibiotics started and tailored to resistance genes in 24 to 48 hours (urine culture 48-72 hours)

Urine culture unable to identify extended-spectrum β-lactamase, high prevalence

Interstitial cystitis (IC)/pelvic pain: traditional culture misses Ureaplasma, can be seen with positive or negative urinalysis result

PCR test to help delineate IC vs embedded infection

We encourage you to add these types of programs to your group and develop educational policies and reviews, ensuring members of your group comply with the intention of the recommendations.

1. Medicare Program Integrity Manual. Centers for Medicare & Medicaid Services. Accessed November 4, 2022. https://go.cms.gov/3NBT1dV

2. Compilation Of The Social Security Laws. Social Security Administration. Accessed November 4, 2022. https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

3. Title 42—the public health and welfare. Accessed November 4, 2022. https://bit.ly/3SZWjJe

313 F.3d 758, (C.A.2 N.Y., 2002). December 20, 2002. Accessed November 4, 2022. https://caselaw.findlaw.com/us-2nd-circuit/1463839.html

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

"Although Medicare has developed previous coverage directives for several types of PCR tests outside of UTI detection and there are sound arguments for the use of PCR tests in detecting UTIs, Medicare only recently published a local coverage determination that included the use of PCR tests for UTI detection," write Jonathan Rubenstein, MD, and Mark Painter.

How to get reimbursed for multiplex PCR urine cultures

I have heard some individuals are reporting 

 code 64590 when placing an eCoin device. What are your thoughts?

eCoin is an exciting new technology for the management of bladder overactivity that is implanted near the posterior tibial nerve subcutaneously. 

 codes that specifically mention the posterior tibial nerve include 

 code 64566 (posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming) and Category III 

 codes 0587T (percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming and imaging guidance when performed, posterior tibial nerve) along with 0588T (…revision or removal of integrated single device neurostimulation system posterior tibial nerve). There is currently no code that is specific for placing the eCoin. Per AMA guidance, an unlisted 

 code should be chosen when there is no specific code to report that service. If an unlisted code was used to report eCoin, the best code may be 64999 (unlisted procedure, nervous system). 

 code 64590 describes “insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling.” Although one could certainly make a good argument that the eCoin fits this description by being a peripheral pulse generator or receiver, there are others who may question the meaning of “direct or inductive coupling” and the necessity for that in reporting the code.

The coding for this device is reminiscent of initial coding advice and response for percutaneous tibial nerve stimulation (PTNS) and Rezūm. You may recall that initially, coding for PTNS recommended by the manufacturer was to report PTNS with code 64561 based on input from AMA. Initial coding advice from the manufacturer and from Physician’s Reimbursement Services for Rezūm was 53852 based on input from the American Urological Association. In each case, codes specifically addressing each service were added to 

, and reporting followed. In each of these cases, practices had official opinions supporting the use of those codes that were considered close to correct. For eCoin, no official opinion has been issued by 

 code 64590 for reporting the procedure implanting the eCoin device. We advise that each office communicate with a patient’s insurance company about the best code to use when reporting eCoin and to get their policy in writing, and consider getting a predetermination. As there has been no official opinion given, when a payer seen 

 code 64590 being reported in patients with urinary urgency and other bladder-related symptoms the payers may assume that the surgeon is placing a sacral nerve stimulator. The risk of this of course is that if the payer then later realize that an eCoin was placed there is a risk of take-backs of payment if there was no policy in place, the device was felt to be experimental for that insurer, or if there was communication or predetermination of the procedure being performed. If paid under code 64590 and under a false assumption that the service provided was not insertion of eCoin, it could be considered a contractual violation or in some cases fraud. We therefore strongly recommend the use of code 64999 unless otherwise instructed by the payer for reporting eCoin.

eCoin is a new technology for the management of bladder overactivity that is implanted near the posterior tibial nerve subcutaneously.

Jonathan Rubenstein, MD

Articles

How to bill Principal Care Management codes when 2 specialists are involved

Breaking down the CMS 2023 final rule for urologists

How to get reimbursed for multiplex PCR urine cultures

What are your thoughts on reporting CPT code 64590 when placing an eCoin device?