Jonathan Rubenstein, MD

"We have received numerous complaints about the PA and predetermination process. We all wish we could answer this differently and definitively," write Jonathan Rubenstein, MD, and Mark Painter.

"We believe the confusion comes from the typical lexicon surgeons use when performing surgeries, rather than the actual code descriptor and the procedure performed," write Jonathan Rubenstein, MD, and Mark Painter.

Jonathan Rubenstein, MD, and Mark Painter tackle a coding question for treating stones.

Jonathan Rubenstein, MD, and Mark Painter answer a question regarding coding for use of the second-generation Calyxo CVAC system.

"For telephone-only (audio only) visits, Medicare has officially stated that such a visit would be considered the same as an in-person visit, with a few qualifications," write Jonathan Rubenstein, MD, and Mark Painter.

"With the requirements for an E/M code as noted above, we agree with you that the supporting documentation, if appropriately documented, would support a level 3 outpatient visit for a visit regarding counseling for contraception or family planning," write Jonathan Rubenstein, MD, and Mark Painter.

"As we all know, Medicare rules do not always follow CPT directives. The same is true in this case," write Jonathan Rubenstein, MD, and Mark Painter.

"From a coding standpoint and from the work performed and valuation of the work and descriptors, it is appropriate to report the dilation (50436 without or 50437 with new access as appropriate) along with the nephrolithotomy codes (50080/50081) when both are performed at the same time by the same provider," write Jonathan Rubenstein, MD, and Mark Painter.

"Please note that although this starts out as a balloon rather than just the injection of a biodegradable product, this device is actually fully biodegradable and is absorbed within 6 months of insertion," write Jonathan Rubenstein, MD, and Mark Painter.

"If a practice has determined in writing that there are insurers whose policies advised that they will not accept this code, it seems reasonable not to report that code to that insurer even when criteria are met," write Jonathan Rubenstein, MD, and Mark Painter.

"As a result of the changes and the programmed phase-in of the changes, the cystoscopy code total RVU for the office setting will be 8% lower in 2025 than the current value," write Jonathan Rubenstein, MD, and Mark Painter.

"The final rule for 2025 poses several challenges to urology. Lobbying efforts to preserve telehealth access and the CF will continue, perhaps dragging into 2025," write Jonathan Rubenstein, MD, and Mark Painter.

"If the documentation supported the use of modifier –22, it should be appended," write Jonathan Rubenstein, MD, and Mark Painter.

"When determining which code you should use, you must consider your Medicare carrier’s published rules and commercial payer processing policies," write Jonathan Rubenstein, MD, and Mark Painter.

"The CF for 2025 is proposed to decrease to $32.36 from $33.29 in 2024. This is a decrease of 2.80%," write Jonathan Rubenstein, MD, and Mark Painter.

"Nurse practitioners and physician assistants are considered qualified health care professionals and are able by license to supervise diagnostic tests and interpret based upon state laws," write Jonathan Rubenstein, MD, and Mark Painter.

"Documentation must support the existence and treatment of a separate stone," write Jonathan Rubenstein, MD, and Mark Painter.

"Based on your question, C9761 would not be appropriate for using the access sheath," write Jonathan Rubenstein, MD, and Mark Painter.

"The medical necessity of the service needs to be expressed within the documentation submitted," write Jonathan Rubenstein, MD, and Mark Painter.

"Ultimately, it is best to report CPT 50548 (only) for the performance of a typical laparoscopic nephroureterectomy," write Jonathan Rubenstein, MD, and Mark Painter.

"Although the Medicare physician fee schedule, which is typically the primary focus of many of our discussions, is what is used to determine physician payment for a service, payment for an ASC is governed by separate rules," write Jonathan Rubenstein, MD, and Mark Painter.

"We felt that it was important to again address this topic because we have received numerous questions regarding the correct use of this code and we have had some experience using the code now that it is active and been able to observe some of the initial payment processing by the payer," write Jonathan Rubenstein, MD, and Mark Painter.

"To answer this question, one must know what is and is not included in the global payment for the UDS, and the definition and instructions for appropriate use of modifier 25," write Jonathan Rubenstein, MD, and Mark Painter.

"Use code 51702 for the routine insertion of an indwelling bladder catheter, such as a Foley," write Jonathan Rubenstein, MD, and Mark Painter.

"Per CPT coding instructions, when procedures or services performed by physicians do not have a valid or descriptive CPT or Healthcare Common Procedure Coding System (HCPCS) code, the service should be reported using an unlisted code," write Jonathan Rubenstein, MD, and Mark Painter.

"When we think about a typical procedure for performing a radical cystectomy for cancer with an ileal conduit, that would typically involve lymph node dissection, and therefore CPT 51595 would be best chosen to report that combined procedure," write Jonathan Rubenstein, MD, and Mark Painter.

"Based on the definitions from the ASA and coverage rules for Medicare, the use of nitrous oxide for urology procedures is a noncovered service," write Jonathan Rubenstein, MD, and Mark Painter.

"The conversion factor is slated to undergo a reduction of approximately 3.37% for 2024, decreasing from $33.89 in 2023 to $32.74," write Jonathan Rubenstein, MD, and Mark Painter.

"Many of the new codes are CPT Category III codes, which will require additional research for both coverage and payment rates, especially with private payers," write Jonathan Rubenstein, MD, and Mark Painter.

"ICD-10-CM coding denials have been increasing across the country as payers continue to refine edits," write Jonathan Rubenstein, MD, and Mark Painter.