Opioid prescribing for patients receiving prostatectomy or nephrectomy was significantly reduced using a multi-pronged behavioral intervention, according to research published in 

The primary outcome measure was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The results showed that in patients receiving prostatectomy, the median OMEs prescribed decreased from 195 to 19 with the intervention, and among patients receiving nephrectomy, the median OMEs decreased from 200 to 0 (

 <.05 for both). The decreased opioid prescribing did not negatively affect patients’ perceptions of the quality and efficacy of their postoperative pain management.

The study findings show that, “It is possible to perform major urologic surgery with minimal to no opioid use after discharge without compromising patient-reported outcomes,” study author Bruce L. Jacobs, MD, MPH, assistant professor of Urology, Department of Urology, University of Pittsburgh School of Medicine, told 

. “A thoughtful, multi-pronged intervention can have a desired effect on physician behavior even after the intervention is stopped.”

The single-institution (University of Pittsburgh), single-arm study assessed opioid prescribing by urologists for adult patients who received a prostatectomy or nephrectomy from November 2018 to July 2019. The prescribing patterns of 13 urologists were examined for the study.

The multi-pronged behavioral intervention had 3 components. The first involved a grand rounds presentation to urology surgeons and residents informing them of the risks of patient opioid abuse after surgery. The staff members were educated on available nonopioid regimens for managing pain. The second component was individual audit feedback related to individual prescribing patterns over the previous month. Emails and text messages were used as part of the feedback mechanisms. The final part of the intervention was a monthly comparison report distributed to the entire department listing the number of opioids prescribed by each surgeon.

The study included pre-intervention, intervention, and washout phases. The pre-intervention phase consisted of the 4-month period prior to the intervention during which the investigators compiled the baseline numbers for surgeons’ opioid prescribing. The intervention phase was the 6-month period during which the intervention was implemented. The washout phase was the 3-month post-intervention data collection period.

Overall, 382 patients received prostatectomy, including 120 in the pre-intervention phase, 178 in the intervention phase, and 84 in the washout phase. Patient demographics were similar across the 3 phases. The rates of open versus minimally invasive surgery were 44% versus 56%, 37% versus 63%, and 38% versus 62%, in the pre-intervention, intervention, and washout groups, respectively.

Among the 306 patients who received nephrectomy, the breakdown by phase was 92 in the pre-intervention, 142 in the intervention, and 72 in the washout. Almost 60% of patients received partial nephrectomies across the 3 groups, and 3% of patients underwent nephroureterectomy. Patients characteristics were similar across the 3 groups, except that fewer patients in the washout phase had hospital stays lasting 3 or more days.

For both types of urologic surgery, there was a significant decrease in the median OMEs prescribed between the preintervention phase and both the intervention phase (

= .01). It is noteworthy that the reduction in opioid prescribing held up throughout the washout period, even though the intervention had stopped.

Beyond assessing opioid prescribing patterns, the investigators used the International Pain Outcomes questionnaire to evaluate patients’ perceptions of their pain management care following surgery. Patients were given the surveys at their 2-week post-surgery follow-up. 

The questionnaire results showed that anxiety levels were higher among patients who underwent prostatectomy and were discharged with opioids compared to the levels for patients discharged without opioids (

<.05). Beyond this finding, however, patients receiving either surgical procedure discharged with and without opioids had comparable perceptions of post-surgery pain management, activity levels, somatic symptoms, and psychiatric symptoms.

The authors noted in their concluding remarks that they are not in favor of a complete elimination of opioid prescribing. “We are not advocating for no opioids in all cases. Some patients, such as those with prior opioid use, may require opioids. However, the majority of patients will not need opioids after discharge.”

1. Jacobs BL, Rogers D, Yabes JG, et al. Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery [published online October 1, 2020]. 

Articles

The intervention led to a significant reduction in urologists' opioid prescribing after prostatectomy and nephrectomy. 


Opioid prescribing after urologic surgeries lowered with novel intervention

What are some financial planning tasks I should focus on before year end?

The quickly approaching year end presents the perfect opportunity to review and possibly adjust your financial planning strategies. A lot can happen in a year, and you should be updating your accounts and checking in on where you stand with many of the goals you set at the beginning of the year.

Check on the status of your emergency fund. 

Did you need to dip into it at all this year? Have your necessary expenses changed? It’s always a good idea to review the balance of the account as well as your budget to see if additional funds need to be added to bolster the account. The general rule of thumb for emergency funds is to have 3 months of necessary expenses if you are a dual-income household and 6 months to a year if you are a single-income household.

401(k) with a previous employer: What are your options?

You have until the tax filing date next spring to make a 2018 contribution to an individual retirement account (IRA), but 401(k) and 403(b) contributions are only deductible when made in the same calendar year. The 2018 contribution limit is $18,500 for 401(k)s and 403(b)s and $5,500 for IRAs. If you are over age 50, catch-up contributions may be available as well.

Use the remaining money in your Flexible Spending Accounts. 

If you still have money set aside in a flexible spending account for health care or dependent care expenses, it is important to try and use those funds before the end of the year or risk forfeiting the money. Some employers offer a grace period into the spring of the next year or a $500 flexible spending account carry-over from 1 year to the next, but most do not.

Make contributions into your children’s 529 accounts. 

College costs continue to rise, and it is important to start saving early if you hope to reach your college funding goals. Additionally, in some states, a state income tax deduction is offered to residents who contribute to their 529 plan. In some cases, the tax savings can be substantial.

Designate those individuals to whom you wish to gift assets

Designate those individuals to whom you wish to gift assets. 

The annual gift tax exclusion is $15,000 for 2018 ($30,000 for married couples). You can gift this amount to any number of individuals without having to pay gift tax or have it count against your lifetime gift and estate tax exemption.

Giving to charity can be a very powerful tax-savings tool. Check and see if you have any appreciated investment assets that you could gift instead of cash. This way, you avoid paying capital gains taxes on those investments and are able to claim a deduction for the full value of the donated asset. When the charitable organization sells it, there's no tax to them. Be aware, however, that under the new tax law, you may need to donate a substantial amount of assets to be eligible for a charitable deduction on your taxes.

How can rising interest rates affect your bond portfolio?

These are just a handful of financial issues to consider as we approach year end. Your financial and legal advisers can run through a more comprehensive checklist of planning options based on your personal circumstances.

My 401(k) has a vesting schedule. What does vesting mean?

Many employer-sponsored retirement plans have a vesting schedule to incentivize employees to remain with the company long term. Vesting refers to ownership and means that, even if your employer made matching contributions, you may not fully own those assets yet. While you are always 100% vested in the salary deferral contributions you make to the plan, ownership of employer contributions is gained over time.

Vesting schedules may be graded, giving you increased ownership of employer contributions each year. For example, after 1 year of service you may be 20% vested and after year two, 40%, and so on until you are 100% vested. Graded schedules can be no longer than 6 years.

Alternatively, the plan may have a cliff vesting schedule. Just like it sounds, this provision means that for a certain period of time, you won’t be vested at all. Then, like going off a cliff, you become 100% vested all at once. If your employer selects a cliff vesting schedule, the cliff can be no longer than 3 years of service. With either type of vesting schedule, the definition of service can vary, so be sure to read the plan document.

Mr. Witz is educational program director at MEDIQUS Asset Advisors, Inc. in Chicago. He welcome readers’ questions and can be reached at 800-883-8555 or 

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice.

Take time to review your emergency fund and max out retirement account contributions.

As 2019 nears, focus on these financial planning tasks

The federal Stark physician self-referral law and federal Anti-Kickback Statute threaten to derail the federal government’s value-based care initiative unless changes are enacted so alternative payment models can be developed without participating physicians risking violating these laws.

That’s the view of LUGPA and Gary M. Kirsh, MD, past president of that organization and chair of LUGPA’s Alternative Payment Model Task Force. Dr. Kirsh testified before the House Ways and Means Subcommittee on Health in July as Congress is currently considering legislation to update Stark.

The concept of value-based care was set forth in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which repealed the sustainable growth rate formula for Medicare payments to physicians, changed the way Medicare rewards clinicians for value over volume, streamlined multiple quality programs under a new Merit-based Incentive Payment System, and provided for bonus payment for participation in eligible alternative payment models (APMs).

“Unfortunately, the vision of MACRA and value-based delivery is in jeopardy,” Dr. Kirsh told lawmakers at the hearing, noting that only 5% of U.S. physicians participate in an APM and there are almost no APMs in the pipeline for approval.

Last year, LUGPA developed a urology-specific APM that would give physicians incentives to pursue active surveillance rather than active intervention in patients with localized prostate cancer. It is predicated on the belief that many patients who receive active intervention could benefit from having that deferred, thus avoiding overutilization of services while reducing morbidity and cost.

AUA, AACU back Good Samaritan legislation

Like all proposed APMs, LUGPA’s proposal must be approved by the Department of Health and Human Services’ (HHS) Physician-Focused Payment Model Technical Advisory Committee, and if approved there, by HHS.

But the Stark law gets in the way, said Dr. Kirsh.

“Existing Stark and associated fraud and abuse laws are one of the principal barriers to the development of APMs and the advancement of value-based care,” he said, noting that it was written 30 years ago and has not been modified since 1993.

“Congress recognized long ago that the Stark law was an obstacle to care coordination and value-based delivery when it authorized the Secretary of Health and Human Services to waive the self-referral and anti-kickback prohibitions for accountable care organizations,” he said. “Yet independent physician practices were left behind. Congress should level the playing field to provide these same protections for independent physicians to test and participate in APMs.”

For now, unless waivers are approved on a case-by-case basis, organizations wishing to develop APMs “find themselves in a catch-22,” said Dr. Kirsh. “They cannot test an APM in the real world without financial waivers to Stark and anti-kickback laws, yet these waivers cannot be granted unless there is an approved APM.”

Dr. Kirsh noted that organizations such as LUGPA may spend years of work, resources, and substantial investments designing an APM, “but it remains a theoretical, mathematical model whose actual impact on patient care and health care financing is unknown without testing in the clinical environment.”

Essentially, that is why LUGPA and 24 other physician groups have endorsed the Medicare Care Coordination Improvement Act (H.R. 4206), “which provides a means for the [HHS Office of Inspector General] to grant waivers to test a proposed APM when it is submitted in writing and approved by the [HHS] Secretary,” Dr. Kirsh said. The waivers would have to be recertified every 6 months until the APM is approved or denied.

Dr. Kirsh explained to Health Subcommittee members that the Stark law also represents a barrier to the development and adoption of APMs because it explicitly prohibits remuneration of physicians who receive revenue from designated health services based on the “volume or value” of their referrals to these services.

“While this may be crucial in fee-for-service models, this hampers practices from incentivizing physicians to adhere to treatment pathways and agreed-upon clinical guidelines that improve patient outcomes and promote efficient use of health care resources in the context of an APM,” said Dr. Kirsh. “Current Stark law prevents practices from utilizing revenue from designated health services to financially reward or penalize physicians for adherence or deviation from clinical best practice standards or appropriate increases or decreases in utilization of services.”

LUGPA president details decade of successes with eye on future

What is needed, said Dr. Kirsh, is elimination of “volume or value” from Stark prohibitions for the testing and operation of APMs, which would “result in a clean, targeted, modernized version of the Stark and anti-kickback statutes.”

This, he said, is needed for clinicians to be willing to enter into APMs, which by definition limit financial exposure to the Medicare program.

According to Deepak Kapoor, MD, chairman of LUGPA’s Health Policy Committee, holding clinicians harmless for APM participation is simply a matter of common sense.

“How can you have value-based care if you are not allowed to compensate physicians based on value?” Dr. Kapoor asked in an interview with 

“I think this is something that everybody acknowledges has got to get done.”

Certainly, physicians will not knowingly risk violating Stark, which could subject them to treble damages regardless of their intent, he said.

“Congress needs to enact these reforms if we are to move forward with value-based care.

“Existing Stark and associated fraud and abuse laws are one of the principal barriers to the development of [alternative payment models] and the advancement of value-based care,” says Gary M. Kirsh, MD.

LUGPA urges Congress to update Stark law

What is the best way to charge for a consult at the hospital that does not require a significant physical exam? For example, I was asked to see an old Medicare patient of mine who was in urinary retention following a major surgery. My billing department told me that I could not charge without documenting a physical exam.

You have asked a very important question for urologists. First and foremost, your billing department is correct. A Level 1 initial hospital care code requires a detailed physical exam (at least four exam points for the affected organ system, in this case the genitourinary system, and at least four exam points in other organ systems).

Without the required history and physical exam, we recommend using the subsequent hospital care code that is satisfied by your documentation for the visit. Some medical directors have recommended using an unlisted evaluation/management code; however, this method of reporting is much more problematic and should be pursued only if required by the payer.

For future consults that do not require a significant amount of physical exam, we recommend considering charging by time, if over 50% of the time has been spent in counseling the patient and coordinating care. Charging by time in the hospital includes the total time spent on the floor, talking to the nurse, reviewing the chart, discussing the issue with the patient, taking a history, performing the medically necessary physical exam documenting the encounter, etc. Three things should be recorded in the chart:

specific total time indicating the time spent with the patient, and the floor time as indicated above

time spent in counseling the patient or include the statement that “over 50% of the time was spent in counseling and coordinating care”

The average time to accomplish a Level 1 recorded in the CPT book is 30 minutes. This is considered an average time and not a “threshold” time. If you spend less than 30 minutes, you can still charge this code (99221).

Is −25 modifier needed for E/M service when charging in conjunction with 5XXXX code?

My biller said she heard at one of your seminars that we did not need to append a −25 modifier to an E/M charge in conjunction with 51798. This does not seem to be correct. I specifically remember being told many years ago that we had to attach a −25 modifier to any E/M service when charging in conjunction with any 50000 code.

We’re glad you asked that question. We can see that there is still lot confusion on this issue, as we audit hundreds of urology charts each year.

Can you bill a urethral suspension with radical prostatectomy?

Many years ago, what you were told was correct. All of the 5XXXX codes were either 0-, 10-, or 90-day globals. Charging an E/M service with any CPT code from the Surgery section would require the appropriate modifier, and –25 is the most appropriate in the majority of cases.

However, as time changes, so do Medicare rules. Your biller is correct at this time. When billing Medicare, you do not need a –25 modifier attached to the E/M when billing with 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging).

51798 is listed as “Global:XXX” and by definition, the global concept does not apply to the code. Uroflow (51736 and 51741) and electromyography (51784 and 51785) are also classified as XXX procedures. For Medicare patients, do not add the −25 modifier to an E/M code when billing in conjunction with an XXX global procedure. In addition to the above, 51741, all laboratory services (including urinalyses), and imaging procedures are listed as XXX global services.

The exception to that rule are the few XXX procedures/services that include E/M services in the bundled service list under the NCCI edits.

An example of an XXX global procedure that requires a modifier for an E/M code reported on the same date is 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic).

NP, PA incident-to billing: What is (and isn’t) allowed

If you check the bundling matrix in AUAcodingtoday.com, you will be able to see if a modifier is required for E/M code by entering all codes to be charged that date and clicking “analyze codes.” The bundling matrix will indicate whether an E/M code needs a modifier for either an NCCI bundle or a global period bundle.

Question regarding laparoscopic pyeloplasty and stent placement through ureterotomy

I have a two-part question for you. First, if you perform a laparoscopic pyeloplasty, can you bill 50605 as well as for stent placement through a ureterotomy? My hospital system is saying they are bundled, but I don’t think they are. Second, when I do a ureteroureterostomy, I feel code 50605 should be allowed, but they keep denying my coding. Can you help me to set the record straight?

Regarding your first question, the description of 50544-Laparoscopy, surgical; pyeloplasty-does not include insertion of a stent in the description. Nor is there a different code that would include both the stent insertion and pyeloplasty. Therefore, from a CPT coding perspective, it is appropriate to look for a code that would describe the insertion of a stent to report in addition to the laparoscopic pyeloplasty.

Unfortunately, CPT does not include a code for laparoscopic insertion of stent. Expanding the search, we find two potential codes that could be considered: 50605 (Ureterotomy for insertion of indwelling stent, all types) and 50949 (Unlisted laparoscopy procedure, ureter). Choosing which code to use is a bit of debate. Code 50605 does not specify approach in the description. The AUA has recommended in other cases for circumstances in which there is no existing laparoscopic code for the procedure performed, with payer notification, a code considered to be traditionally provided with open approach but without a specified approach in the descriptor can be reported for the service. Note that payer notification is recommended prior to reporting the service. Many groups are successfully reporting in this manner.

How to set up e-prescribing for controlled substances

However, for those instances where the payer prefers the use of the unlisted code or in circumstances in which the compliance program for the billing entity requires reporting of the unlisted code specifying approach, the unlisted code with reference to the compatible open code should be reported.

Neither of the codes are considered bundled with the pyeloplasty code in the National Correct Coding Initiative (NCCI) bundling edits. Therefore, you should charge separately for the insertion of the stent when medically necessary. It should be noted that not all payers conform to NCCI bundling edits; as such, you may encounter some payers that will not allow separate payment for the stent insertion.

Finally, NCCI edits change quarterly. This answer was correct at the time of publication, but you will need to make sure that edits do not change for future billings. Note: As we have stated many times before, documentation for all procedures should support the medical necessity for performing that procedure at that encounter. If medical necessity cannot be supported, the procedure should not be charged.

Addressing your second question, the description of 50760 (Ureteroureterostomy) does not include insertion of the stent. The two codes are bundled in the NCCI, but could be unbundled with the modifier. However, since the stent is being inserted because of the procedure and is related to the procedure, there is not a good modifier that will pull you out of the bundle. We would recommend that you not bill for the insertion of the stent separately.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at 

 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.

Charging by time is permissible with appropriate documentation, according to Ray Painter, MD, and Mark Painter.

Vol. 46 No. 11

Opioid prescribing after urologic surgeries lowered with novel intervention

As 2019 nears, focus on these financial planning tasks

LUGPA urges Congress to update Stark law

How to bill for hospital consults without physical exam