Jonathan Rubenstein, MD

Pathologic tissue confirmation is usually the best practice.

Payer edits referencing ICD-10-CM guidelines such as “Excludes 1” are on the rise.

Increase in conversion factor and delay of sequestration are among changes.

Check for surgical approach and bundling edits when choosing a code.

Urology as a specialty will see a 3.71% decrease in overall payments.

"As always, document well and use the modifiers when appropriate," advise Jonathan Rubenstein, MD, and Mark Painter.

"The short answer is that this will be paid once," according to Jonathan Rubenstein, MD, and Mark Painter.

Code selection will depend on the size of the stone being treated.

New and updated codes encompass balloon continence devices, hypospadias

"When taking into account the various rules surrounding both codes, 52310 or 52315 should be reported with 1 unit for the removal of bilateral stents," write Jonathan Rubenstein, MD, and Mark Painter.

"Each bill that is submitted for reimbursement must have a code for both the service performed and a reason for the service," writes Jonathan Rubenstein, MD, and Mark Painter.

Medicare typically does not pay for preventive services unless specifically allowed.

Conversion factor is expected to decrease by 3.89%

"Depending on the age of the surgeon, one may be surprised to hear that it was common to perform a vasectomy routinely on patients undergoing a TURP procedure," write Jonathan Rubenstein, MD, and Mark Painter.

"It is clear that if a practice were to require or encourage all or some of their patients to supply their own catheters, it would be considered a violation of your Medicare participation and could result in takebacks, fines, or even exclusion from Medicare," write Jonathan Rubenstein, MD, and Mark Painter.

SHIM and other questionnaires do not satisfy categories within Data section.

"Either way the service is reported, the payer should require documentation be submitted for review prior to payment, and the use of the –52 on the 38571 will provide more appropriate guidance for reimbursement processing," write Jonathan Rubenstein, MD, and Mark Painter.

"Determining the PVR as part of a urodynamics test is part of the test itself and included in the payment already," write Jonathan Rubenstein, MD, and Mark Painter.

Include clear reason/diagnosis for each test, image, and diagnostic service ordered.

Physician involvement in responses to payer audits is crucial.

"There are a number of physicians who would not feel comfortable using the word 'complete' unless they were confident that all prostate tissue had been removed," write Jonathan Rubenstein, MD, and Mark Painter.

"Placing a catheter to irrigate obstructing blood clots (CPT 51700) is specifically included in the payment for the TURP if this complication is managed outside of an operating room," write Jonathan Rubenstein, MD, and Mark Painter.

Medical necessity must be documented on the chart in order to bill code.

Providers must carefully outline their clinical thought process.

"Unfortunately, we have found that most if not all insurers do not pay for this code and additionally often have policies against charging patients for extra supplies, and balance billing would be a violation of their contract," write Jonathan Rubenstein, MD, and Mark Painter.

“If one performs a bladder catheterization to obtain the post-void residual, use CPT code 51701,” write Jonathan Rubenstein, MD, and Mark Painter.

Recent legislation appears to have delayed implementation of the new code.

CMS also expands the number of services payable under telehealth.

Evaluation/management changes should benefit providers and patients.