Mark Painter

As the year comes to a close, we revisit some of this year’s top content on urology coding and reimbursement.

"The overall 0% impact to urology does not help urology practices deal with increasing costs incurred for staff, rent, supplies, and other overhead," write Jonathan Rubenstein, MD, and Mark Painter.

"Based on the code description, we recommend basing the code selection on the documentation and the effort required to complete the service, and not the number of foreign bodies removed from the bladder," write Jonathan Rubenstein, MD, and Mark Painter.

"Based on this proposal, some shifts may significantly impact the practice of urology," write Jonathan Rubenstein, MD, and Mark Painter.

"It is common for a payer to request patient records when submitting for a service with a category III code," write Jonathan Rubenstein, MD, and Mark Painter.

"As with all medications and services, it is important to check with the patient’s insurer to determine their policy and whether the medication will be covered," write Jonathan Rubenstein, MD, and Mark Painter.

"As always, we encourage you to communicate among all team members and pay attention to your documentation," write Jonathan Rubenstein, MD, and Mark Painter.

"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.