Making heads or tails of the financial news can be difficult. What does it really mean when the market was up or down? News reports about the stock market that you see or hear every day often report the movement of groups of stocks, and much less so the price movement of an individual company’s stock. “The Dow Jones Industrial Average (DJIA) was up 120 points today” or “the S&P 500 remained relatively flat today” are common vernacular you may hear financial news pundits use.

Citing a specific index or average provides a general sense of the direction of stock prices. They will not, however, tell you whether the stocks in your own portfolio are up or down. Understanding what these reports mean is important because they are commonly used as benchmarks to measure the performance of individual stocks.

Stock indexes and averages are simply ways to measure changes in the market value of certain groups of stocks. An average, as the name implies, is the arithmetic average price of a group of stocks. The DJIA is such an average. Made up of 30 large industrial stocks, the DJIA was originally calculated by adding up the prices of the stocks included in the average and then dividing by 30. This divisor has been adjusted numerous times to account for mergers, stock splits, and other factors.

An index, on the other hand, is a total value expressed in relation to a previously determined base number. The S&P 500 (formerly known as the Standard and Poor’s 500 index), for example, uses a base value of 10. The total market capitalization of all companies in the S&P 500 is about $33,391,900,000,000 as of September 10, 2020. To make this number more easily reportable, the base value of 10 is applied, and the number is reported as 3,339.19.

It is also important to understand the components of the most commonly used indexes and averages:

 This index is the benchmark against which many portfolio managers compare themselves. It consists of 500 blue-chip stocks, separated by industry, so that almost all key industries are represented.

 The commonly quoted average tracks the price-weighted movement of 30 of the largest blue-chip stocks traded on the New York Stock Exchange.

This index tracks the movement of all companies traded on the Nasdaq Stock Market, which tend to be smaller and more volatile than those in the DJIA or the S&P 500. The Nasdaq is market-value weighted, giving more influence to larger and higher-priced stocks.

This is the key barometer and indicator of companies on the smaller end of the capitalization spectrum. This domestic small-cap index is made up of the bottom two-thirds of the Russell 3000 index, a larger index of 3000 publicly traded companies that represent nearly 98% of the investable US stock market.

 This market-weighted index consists of about 1600 foreign stocks listed on the exchanges of 22 developed countries (excluding the United States and Canada), representing all major industry groups.

Index and average tracking can be very useful as a comparison against your own portfolio. But a valid comparison depends on your ability to determine which index is the best benchmark for your holdings. Remember, none of these indices is available for direct investment. You can, however, buy mutual funds and exchange traded funds designed to resemble a certain index.

 is educational program director at MEDIQUS Asset Advisors, Inc in Chicago, Illinois.
He welcomes readers’ questions and can be reached at 800-883-8555 or witz@mediqus.com.

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice. If you would like assistance with your individual investment strategy, please email witz@mediqus.com.

Articles

Reports on indexes and averages can help benchmark stock performance.

Financial news: What does it mean and how can it help you?

offers perspective on noteworthy research in the peer-reviewed literature. Dr. Mian is professor of surgery in the division of urology at Albany Medical College, New York.

Although the physiologic adverse effects of androgen-deprivation therapy (ADT), such as hot flashes, fatigue, osteoporosis, and sexual dysfunction, are regularly discussed with patients, the neurocognitive complications (such as depression, cognitive decline, and dementia) are often overlooked. Despite the reportedly strong association between ADT for prostate cancer and several psychological adverse effects, clinical guidelines to address these issues are lacking. Recently, Siebert et al performed a systematic review of the literature to demonstrate the strength of existing data and to offer recommendations regarding identification and management of neuropsychiatric adverse effects of ADT.

The authors summarized the findings from 48 articles outlining the current evidence for neuropsychiatric consequences of ADT and proposed interventions. They also performed 2 meta-analyses examining the risk of depression and dementia after initiating ADT. The data from prospective, controlled studies demonstrate a causal relationship between ADT initiation and incidence of clinical depression. Results suggest that ADT initiation not only worsens pre-existing depression (in as early as 1 month), but may also trigger the development of clinical depression after approximately 1 year on treatment.

A study of patients in the Danish Prostate Cancer Registry showed an association between ADT and depression (HR, 1.8; 

 <.001) after adjustment for comorbidities. Their data suggest that ADT exposure is a risk factor for the development of depression, especially when used with concurrent radiation therapy. Meta-analysis of studies in this report demonstrates 1.51 times (

 = .0002) increased risk of incident depression after ADT exposure.

A dose-dependent relationship between the duration of ADT and depressive symptoms has been demonstrated in several studies. Among prostate cancer patients in the TRICARE military database (n = 9117), ADT was associated with a higher incidence of depression (HR, 2.07; 

<.001), which worsened with the duration of therapy. This dose-response relationship between ADT and depression has also been demonstrated in Chinese and Australian populations. Cumulatively, these data demonstrate significant risk of incident depression and worsening symptoms in men with depressive disorder after initiating ADT.

The data on ADT-related cognitive impairment can vary, depending upon the study population and methodology used to measure the outcome. ADT, compared with healthy controls, was associated with decreased short-term memory and working memory (

<.02). A prospective study of men starting ADT compared with matched individuals undergoing prostatectomy showed higher rates of cognitive impairment at 6 and 12 months. Similarly, men initiating ADT (vs prostatectomy) had a negative impact on language ability and short-term memory capacity (

<.05). These findings suggest an association between ADT and cognitive impairment such as memory loss can be detected as early as 6 months after initiating ADT.

Several large, American studies have demonstrated a consistent association between ADT and subsequent development of Alzheimer dementia (AD). As compared with non-ADT prostate cancer controls, men receiving ADT were at increased risk of AD (HR, 1.14; 

 <.001) and all-cause dementia (HR, 1.20; 

 <.001), dependent upon the duration of ADT. A study of men in the SEER-Medicare database found that those receiving ADT were 20% more likely to develop AD, after controlling for race, ethnicity, prostate cancer stage, and comorbidities.

Another analysis of SEER data of men receiving ADT demonstrated a dose-dependent increased risk of all-cause dementia and AD at 22% and 29%, respectively. ADT exposure for at least 7 months was associated with a 41% increase in all-cause dementia and 30% increased risk of AD compared with prostate cancer controls without ADT. Meta-analysis of several non-American population data sets showed approximately 1.45 times (

 = .02) increased risk of all-cause dementia after ADT exposure.

The authors recommend brief baseline affect and cognitive screening assessments in all patients initiating ADT, particularly those with prior diagnosis or treatment for depression or cognitive impairment. One of the challenges in identifying neurocognitive dysfunction in men receiving ADT is that several of the symptoms overlap with the symptoms of hypogonadism (such as fatigue, lack of desire, and decreased mental sharpness). The authors recommend that all patients starting long-term ADT be counseled regarding possible neuropsychiatric adverse effects, and provided some information about the connection between ADT and mental health. Knowledge of these potential adverse effects can reduce the negative psychological impact or stigma associated with discussion of mental health issues.

Although urologists are quite adept at identifying and addressing the links between urologic conditions/treatments and non-urologic conditions (erectile dysfunction and coronary disease; ADT and osteoporosis), discussion about mental health are often omitted. In any patient receiving ADT for more than 6 months, a patient-administered assessment tool, the Patient Health Questionnaire-9, can be used to screen for depressive disorder. A simple query by the providers, such as “have you been feeling down,” can open the door to acknowledging mental health issues, facilitating a discussion or referral to a mental health professional. As the primary care physicians for prostate cancer, and the main prescribers of ADT, we, the urologists, owe it to our patients to address both the physiologic and the neuropsychiatric adverse effects.

1. Siebert AL, Lapping-Carr L, Morgans AK. Neuropsychiatric impact of androgen deprivation therapy in patients with prostate cancer: current evidence and recommendations for the clinician. 

 Published online July 17, 2020. S2405-4569(20)30149-8. doi:10.1016/j.euf.2020.05.014

Cognitive screening is recommended in patients receiving androgen-deprivation therapy.

Neuropsychiatric effects of ADT often overlooked 

Recently, a number of companies have come out with an option for patients to perform uroflow at home, whether by a smartphone app or using a stand-alone device. The stand-alone device at times can be owned by the practice. The question asked is whether there are billable services around the performance of a home uroflow. The answer is yes, to a point and if done appropriately. However to understand what is and is not billable, we need to break down the components of a uroflow, the currently available CPT codes, expenses incurred by a practice and the work performed by a physician.

Uroflowmetry is coded using CPT code 51741 (Complex uroflowmetry [eg, calibrated electronic equipment]). Uroflow is traditionally performed in a physician’s office at the time of an office visit. The equipment itself is usually owned or leased by the practice.

This CPT code has both a technical (for owning/upkeep of equipment) and professional (interpretation) component. If a uroflow is performed in the office setting using physician-owned (or leased) equipment, CPT code 51741 is billed without a modifier. However, if a uroflow is performed in the patient’s home and not using the practice’s uroflow machine, only the professional (interpretation) component can be billed. Therefore, modifier –26 should be appended to the code to communicate the request for reimbursement for the work of the interpretation of the uroflow (only). Data obtained by the patient in their home can be transmitted to the provider for interpretation, or brought in and interpreted at the time of the office visit (assuming the process adheres to HIPAA rules). As the physician performs the interpretation in the office, the appropriate place of service is Office (Place of Service 11).

If the physician owns or leases the equipment that the patient uses for a home uroflow, there is some debate as to how best to address the technical component. Under these circumstances, the practice is paying for the device and its maintenance between patient use; however, the practice is not providing a typical general supervision of the technical collection of data as compared with the in-office uroflow test. We would interpret the place of service for the technical component for a home uroflow test as Home (Place of Service 12). The professional component is typically provided in the Office setting (11).

Medicare has assigned a different status to the supervision of the technical component (–TC). As the “–TC” requires “direct supervision of a physician” or under incident to guidelines in the office setting, reporting 51741-TC would indicate that the physician was either present during the performance of the service or using video and audio technology to supervise the uroflow test. Therefore, we do not feel it is appropriate to report the 51741-TC with place of service Home (12) for home uroflow tests unless they were supervised. The debate surrounding the reporting of code 51741 if the office supplies the equipment concerns the supervision rules of the global code or 51741 without a modifier. 51741 without a modifier or with a –26 modifier is covered under general supervision, which does not require physician presence during the performance of the test. Therefore, reporting with either place of service (Place of Service 11 or 12) would not require the direct presence of the physician.

Additionally, payers have instructed physicians to report the technical and professional services provided by the same office under the global code (no modifier) based on the date of technical services, regardless of whether they provide the professional and technical services on the same date.

Although we can agree there is some gray area with these new types of services, it is our opinion, based on Medicare intent, that reporting the technical component even when the equipment is owned or leased by the practice should not be done for home uroflow tests either under the global (51741 with no modifier) or the –TC (51741-TC). Medicare rules specify an MUE (Medically Unlikely Edit) of 1 for the 51741 and will only allow for 1 test per date. If the test is being performed at home and results transmitted to the physician’s office, only one 51741 can be submitted per date of service regardless of whether it is submitted as global (no modifier), professional (26), or technical (–TC). If multiple uroflow interpretations are provided on separate dates the service can be reported once per date the tests are interpreted.

As is typically the case, the overarching criteria for billing is medical necessity. If a physician determines based on relevant clinical data that the home uroflow test is equivalent to the office-based procedure as a diagnostic test, they can order it. The payers will also have an opinion based on current literature; therefore, a practice wishing to use the technology should check with payer coverage for each technology. The frequency or number of uroflow tests is also being studied. Currently, we do not find a frequency limitation for uroflow tests outside of the 1-per-day limitation; thus, payment for multiple uroflows provided on different dates is allowed by many payers. Again, we point to medical necessity with regard to the frequency of tests. We have heard from several urologists and have read studies that support the use of home uroflow and multiple uroflow tests for improved diagnosis and are refraining from comment in regard to actual medical necessity, as is our tradition; our comments here are intended to focus solely on billing concerns.

If the results are interpreted at the time of a follow-up office visit, billing can be done at that time. It is important to remember that the 2021 E/M guidelines clearly state that the interpretation of data separately reported (or separately paid) cannot be counted toward the “data” section of medical decision-making.

There are other codes that one can consider billing for remote interpretation of uroflow and patient management without the patient coming in for a follow-up office visit, including the following:

• CPT code 99091 (Collection and interpretation of physiologic data [eg, ECG, blood pressure, glucose monitoring] digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation [when applicable], requiring a minimum of 30 minutes of time, each 30 days)

CPT code 99091 can be used if a physician or other qualified health care professional collects and interprets physiologic data, such as blood pressure, which is stored digitally and may be transmitted by the patient and/or the caregiver to the provider. To bill this code, the provider should create a report that describes the time it took to acquire the physiologic data, review and interpret the data, and modify any care plan as a result of the additional data acquisition. The provider must spend a minimum of 30 minutes every 30 days in the collection and interpretation of data to report this service. Work involves the physician spending more than 30 minutes during a 30-day period for the review, interpretation, and report based on the physiologic data and diary. The intraservice period may also involve communication (eg, phone calls or emails) with the patient to provide medical management and monitoring recommendations related to data collection and interpretation. Postservice work includes associated chart documentation. “Incident to” services provided by staff and conforming to Medicare guidelines may also be included to assist in the collection and interpretation of data.

Therefore, to use this code, the documentation must indicate that services longer than 30 minutes within a 30-day period were spent assisting in the collection and interpretation of a series of home uroflows and developing a report. If this code is used, physicians cannot also bill for the individual uroflows themselves, because that would be akin to being paid twice for the performance of 1 service, and you cannot bill for items or services that are separately reportable.

• CPT code 99457 (Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes)

CPT code 99457 requires 20 minutes or more of clinician time or incident to staff time per calendar month. Based on interpreted data, the physician or other qualified health care professional uses medical decision-making to assess the patient’s clinical stability, communicates the results to the patient, and oversees the management and/or coordination of services as needed, for all medical conditions. The device used must be a medical device as defined by the FDA, and the service must be ordered by a physician or other qualified health care professional. Providers are instructed not to report services of less than 20 minutes, and to report 99457 only 1 time regardless of the number of physiologic monitoring modalities they perform in a given calendar month.

Note that this CPT code was actually created for cardiology, with the assumption of continuous (24 hours per day, every day) monitoring; therefore, the noncontinuous nature of intermittent uroflow testing may not qualify for the use of this code.

Providers can report encounters in which treatment or diagnostic services are provided prior to or after the analysis of a home uroflow using either remote or in-person standard E/M codes, during the PHE. They can report E/M codes in addition to codes 99091 and 51241-26, with modifiers as appropriate.

Send coding and reimbursement questions to Rubenstein and 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.

Are there billable services related to a home uroflow? "The answer is yes, to a point and if done appropriately," write Jonathan Rubenstein, MD, and Mark Painter.

How to bill for remote uroflow

Women with pelvic organ prolapse are more likely to have persistent overactive bladder (OAB) symptoms after transvaginal mesh surgery if they have a high versus low preoperative Overactive Bladder Symptom Score (OABSS) and International Prostate Symptom Score (IPSS).

In a retrospective study of 102 patients who underwent transvaginal mesh surgery by a single surgeon, a preoperative IPSS storage subscore ≥10 was the most useful predictive factor for the persistence of preoperative OAB symptoms after surgery, reported Atsushi Otsuka, from Hamamatsu University, Hamamatsu, Japan, and colleagues in the journal 

“Interestingly, the present study demonstrated that the preoperative IPSS voiding subscore was also a useful predictive factor for the persistence of preoperative OAB symptoms after surgery although the predictive power did not exceed the preoperative IPSS storage subscore,” the authors wrote. “Although IPSS may not be familiar to gynecologists and urogynecologists, this minimally invasive self-reported questionnaire is useful in counseling preoperative pelvic organ prolapse patients with OAB symptoms.”

The investigators found that among the 54 women in the study with OAB, 20 (37%) had persistent symptoms after surgery, while 34 (63.0%) saw their symptoms disappear.

Among the 20 patients with persistent OAB symptoms postoperatively, 15 had an improvement in their OAB symptoms, while the remaining 5 had unchanged or worsened symptoms.

Total OABSS was significantly higher in patients with persistent preoperative OAB symptoms than in patients without persistent symptoms. On the IPSS, the total score, voiding and storage subscores, and individual component scores were significantly higher in patients with persistent preoperative OAB symptoms than in patients without them.

According to the receiver operating characteristics (ROC) analysis, the area under the curve (AUC) was 0.768 (95% CI, 0.640-0.896; 

 = .001) for total IPSS; 0.819 (95% CI, 0.694-0.944; 

 <.001) for IPSS storage subscore; 0.735 (95% CI, 0.596-0.873; 

 = .004) for IPSS voiding subscore; and 0.693 (95% CI, 0.550-0.835; 

The cutoff value for the IPSS storage subscore that indicated nearly equivalent sensitivity and specificity and that retained the greatest efficiency was 9.5.

The sensitivity of the IPSS storage subscore was 68.4% (95% CI, 43.5-87.4), the specificity was 91.2% (95% CI, 76.3-98.1), the positive predictive value was 81.3% (95% CI, 54.4-96.0), and the negative predictive value was 83.8% (95% CI, 68.0-93.8).

The sensitivity and specificity at the of the preoperative IPSS voiding subscore at the cutoff value of 7.5 was 60.0% and 70.6%, respectively.

“In contrast, several preoperative parameters (age, body mass index, parity, pelvic organ prolapse stage) had no significant impact on the persistence of preoperative OAB symptoms,” Otsuka et al wrote.

They continued, “An advantage of the present study is that minimally invasive self-reported questionnaires were used to determine predictive factors for persistence of preoperative OAB symptoms after pelvic organ prolapse surgery. Further, all patients underwent the same surgical procedure using transvaginal mesh by a single surgeon, reducing bias engendered by the type of vaginal surgery.”

Limitations of the research included the retrospective design and the absence of urodynamic study to evaluate detrusor overactivity and bladder outlet obstruction.

The percentages of patients who had relief of symptoms and persistent symptoms postoperatively “are in line with those generally reported for OAB symptom resolution following surgery for significant prolapse,” Alan J. Wein, MD, PhD (hon), co-director of the Voiding Function and Dysfunction Program at Penn Medicine, Philadelphia, wrote in an editorial comment on the research published in the 

. “It is generally agreed that parity and body mass index are not predictive for OAB symptoms after prolapse surgery,” added Wein.

1. Otsuka A, Watanabe K, Matsushita Y, et al. Predictive factors for persistence of preoperative overactive bladder symptoms after transvaginal mesh surgery in women with pelvic organ prolapse. 

. 2020;12:167-172. doi: 10.1111/luts.12299

. 2020;204(3):623-624. doi: 10.1097/JU.0000000000001180

“Although IPSS may not be familiar to gynecologists and urogynecologists, this minimally invasive self-reported questionnaire is useful in counseling preoperative pelvic organ prolapse patients with OAB symptoms," researchers write.

Preoperative bladder symptom score best predictor of transvaginal mesh surgery success 

Which CPT code would you use for aspirating the sterile water out of an inflatable penile prosthesis? The device wasn’t removed or repaired in any way; it was simply deflated and made inactive.

To answer this question, it is important to understand the approach and exactly what was done. Was the procedure performed with the patient awake and was it an ultrasound (or other imaging)-guided aspiration? Or was this an open/extensive cut-down procedure?

In either situation, an unlisted code may be your only option, as we could not find a code that specifically describes the work performed in either situation, but it might change the code choice or which code is referenced in seeking reimbursement.

If you are aspirating the inflatable prosthesis without using an incision but instead employ a needle to aspirate the sterile water, we would recommend using code 55899 (Unlisted Male Genital System) and base the value reported on code 51110 (Aspiration of bladder; by needle). If ultrasound guidance is used to position the needle for aspiration, we would recommend code 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, and localization device], imaging supervision and interpretation) in addition to the unlisted procedure code.

If the aspiration required an incision and cut-down to the component, you could possibly use code 55408 (Repair of component(s) of a multicomponent, inflatable penile prosthesis). Although what you describe is not specifically a repair, this code does describe making an incision using the same approach as for placement of the prosthesis, cutting down to the area needing to be repaired, performing the repair, and closing the incisions. As the service provided is less than that which would normally be provided and which is described in the code, you should append modifier –52 to the code. If this doesn’t describe the work performed, an unlisted code is your best choice.

Jonathan Rubenstein, MD, and Mark Painter discuss what CPT code to use for aspirating the sterile water out of an inflatable penile prosthesis.

What code is used for aspirating water out of an inflatable penile prosthesis?

Urology Times reached out to 3 urologists (selected randomly) and asked them each the following question: Besides the expansion of telemedicine, how has the coronavirus disease 2019 (COVID-19) pandemic affected your practice?


“For a while, the hospital was not allowing elective surgeries, so we had to cancel procedures considered elective. A lot of patients wanted to stay home, and they canceled their appointments. There were some days we didn’t see a full day of patients, and a couple [of] days when we just closed the office because people wanted to stay home.

I respected that decision, …and worked on other projects so I could make good use of the time. That was probably March and April. By May, we basically had a full load of patients and it’s been very busy in the past few months.

I didn’t have any patients who suffered adverse consequences because of the delays. The urgencies we took care of just as we normally would. Some of the elective follow-up visits we postponed, then they came back a few months later and we’re getting caught up.

We’re taking it in stride. We don’t overbook to the point where we’re overwhelmed, and we’re not exhausting ourselves. We’re catching up.

As I said, none of my patients suffered because of the delays. The people who had true emergencies we took care of, and people who had things that could be electively postponed, we postponed, and now we’re getting back to normal.”

“I’m a transplant surgeon as well as a urologist. We took a big step back when we first had [COVID-19]–positive patients [as] we were concerned about 2 things: Seattle had some of the first documented cases in the US, so we put a moratorium on living-donor transplants which were elective procedures. Then we cut way back on deceased-donor transplants because we [had additional concerns]. First, we worried about immunosuppressing patients who might then be exposed to COVID-19. Second, a lot of our patients come from outside the Seattle area—Montana, Alaska, Idaho. We didn’t want to bring people from low-frequency COVID-19 places into Seattle. That had a pretty significant impact on the transplant side of our practice.

Any time a patient doesn’t get an organ, you can say there’s a detrimental effect, but if you need a kidney, you can live on dialysis. Nobody we’re aware of died because he couldn’t get a transplant.

We’ve restarted both programs. Now that we know more about COVID-19, we realize most transmission is not hospital-acquired; people are getting it in the community. So we feel safe having people come in and stay 3 to 5 days.

We’ve been fortunate; just 1 transplant patient died of COVID-19. She was 6 months out from transplant; she and her mom both contracted it in the community. They came into the hospital and succumbed to the disease. Most of our transplant patients have comorbidities—diabetes, hypertension, [or] they’re elderly––we’ve had no new transplant patients develop it.

We still did cancer surgery. There wasn’t a day I didn’t do something in the operating room, but my clinical practice was down by 50% to 60% for a couple months. We’ve gone back to close to our normal practice now. Volumes are just down about 20%.”

“The most obvious impact is that we all had a shutdown. I practice at the Minneapolis VA hospital. We’re continuing at reduced capacity. So that’s a major thing.

We have a more finite capacity and fixed resources at the VA. The government doesn’t just allow people to work overtime. Work stops at a certain time of day. We’re more restricted than the private sector, so there’s a backlog of cases. Surgery dates we can offer are somewhat in the distant future, making the backlog longer than is already usual at the VA.

I don’t think any patients were actually harmed. I think it’s more psychological. I’m talking mainly about prostate cancer. Once you’re diagnosed with any cancer and have chosen a certain path, it’s hard to understand that you have to wait another couple months to have it taken care of. Patients who were really urgent, however, [were taken care of]. It’s just the additional burden to waiting. We care for many older patients with comorbidities and they’re certainly worried about getting COVID-19.

We’ve had a few patients who had to cancel surgery because they developed COVID-19. Patients of mine developed [it] through community spread, not within the hospital, and they’ve all done OK.

We are catching up. Nobody I’m aware of is overwhelmed; we always have lots of work and stress, but it’s what we’re here for, isn’t it? It’s part of our social contract as physicians.”

"We’re taking it in stride. We don’t overbook to the point where we’re overwhelmed, and we’re not exhausting ourselves," says one urologist.

Besides the expansion of telemedicine, how has COVID-19 affected your practice?

What is the story with the new CPT code 99072?

Payment for the typical resources, supplies, and clinical staff time and effort is included in the value of evaluation and management (E/M) visits and other medical visits. However, up until now there was no code available that could be used to report the additional expenses incurred by practices for the extra supplies, materials, and clinical staff time needed to mitigate the transmission of coronavirus disease 2019 (COVID-19).

CPT code 99072 was created by the CPT Editorial Panel in response to these extra practice expenses associated with patient care during the Public Health Emergency (PHE). Practices can use CPT 99072 to report the additional materials, such as extra cleaning supplies; face masks; personal protective equipment; thermometers; and clinical staff time, including, but not limited to, previsit instructions and office arrival symptom checks, that support the safe provision of 

evaluation, treatment, or procedural service during this unprecedented time. Practices may use this code in conjunction with office visits and other nonfacility services when the office visit or other nonfacility services are rendered during the PHE, as defined by law, if the practice itself incurs such expenses. Unless extended, the current PHE for COVID-19 is scheduled to expire on October 25, 2020.

When reporting CPT code 99072, practices should report the code only once per in-person patient encounter per day regardless of the number of services rendered at that encounter. Code 99072 may be reported during a PHE when the additional clinical staff duties as described are performed by the physician or other qualified health care professional in lieu of clinical staff.

Use CPT 99072 only when safety measures are over and above those usually included during an office visit or service, as opposed to CPT code 99070, which covers supplies, materials, and time used during a typical office visit.

Additional coding guidelines for 99072 include the following:

• The time counted in any other time-based visit or service during the same encounter cannot be counted twice to report this code.

• You do not need to link the code to a particular diagnosis code such as ICD-10-CM U07.1 COVID-19.

• You may report 99072 with an E/M service or procedure even if it is not PHE-related.

• You may report 99072 only once per in-person patient encounter per Provider Identification Number (PIN).

Note that, as of this writing, there has been no definitive payment for CPT code 99072, so it is important that physicians check with their Medicare contractors and insurance carriers.

CPT code 99072 was created in response to extra medical practice expenses associated with patient care during the pandemic. 

What to know about COVID-19 CPT code 99072 for your urology practice

Recent studies suggest that judging stone treatment success on patients’ stone-free status is not aligned with how many patients define success.

The urologists’ stone-free metric doesn’t necessarily take into consideration patient quality of life, which is important to patients and for personalized medicine, according to Kristina Penniston, PhD, RDN, CD, FAND, a senior scientist in urology at the University of Wisconsin School of Medicine and Public Health in Madison.

“Most of us have dismissed patient-reported outcomes as not being hard evidence or data, like when we measure somebody’s stone-free rate by looking at a CT scan or measure stone risk by doing a 24- hour urine collection,” said Penniston, who has published studies on quality of life in patients with kidney stones.

Considering patients’ quality of life when measuring health outcomes is becoming more important not only for reimbursement but for research used in the drug approval process.

“Increasingly, we have to get more comfortable with these ‘murkier’ measures as outcomes, which are probably just as important as the hard data from a CT scan. There are a lot of studies in the health literature suggesting that patients’ own assessment of their health-related quality of life is a very good indicator of their overall health,” Penniston said.

According to Penniston, a decade of research in this area has revealed that urologists usually focus on kidney stone procedure outcomes based on results from surgery. A scan showing the patient is stone free means the outcome is optimal, whereas evidence of residual stones or fragments after surgery suggests the patient may need more surgery or treatment.

The patient, on the other hand, might view another intervention as less desirable than having an asymptomatic stone.

Another example: Patients battling chronic or recurrent stone disease often have anxiety even between stone events. They worry about when the next stone might come. Thus, stone clearance may be the goal for those patients.

Quality-of-life information helps guide not only surgical options, but also medical and preventive stone therapy.

“I work in the world of prevention; specifically, nutrition therapy. There are some patients whose quality of life actually decreases with nutritional therapy. That’s important for us to know and guides us toward alternative approaches and shared decision-making,” Penniston said.

Stone clearance or stone-free rate as an outcome is undeniably important but doesn’t capture all the experiences that can be important to patients. Identifying what is important to patients helps them make better informed decisions, according to Gregory E. Tasian MD, MSc, MSCE, an associate professor of surgery and epidemiology at Perelman School of Medicine at University of Pennsylvania in Philadelphia and a pediatric urologist at Children’s Hospital of Philadelphia.

“Quality-of-life assessment of our patients is probably underutilized,” said Justin B. Ziemba, MD, MSEd, an assistant professor of urology and surgery at the Hospital of the University of Pennsylvania, Philadelphia, who has had studies published on quality of life and stone disease. “We find that not only in kidney stones but a lot of diseases that we study and treat in urology. We tend to focus a fair amount of time on trying to figure out what is the best clinical outcome, which is usually from the perspective of the doctor.”

Patients generally want to know that they are going to feel better and are concerned about pain, according to Ziemba.

“What we [have] found so far is that people tend to think of pain of intensity on the classic 1 to 10 scale. Another important concept is pain interference, which is how likely the pain is to disrupt daily activities,” Ziemba said.

Quality-of-life assessment not only important in adults

Stone disease is rising dramatically among children, according to Tasian.

“Up until about 20 years ago, stones were a condition that occurred predominately in adults. Over the last 20 years, we’ve seen the incidence rise dramatically in children, such that the age group in whom stones are increasing at the fastest rate is adolescents—particularly adolescent girls,” Tasian said.

Unfortunately, little is known about how to best treat pediatric patients with stones, and there is scant evidence on quality of life and stone disease in children, he said.

“Ureteroscopy in an 18-month-old is very different than ureteroscopy in a 60-year-old. With that we have some evidence on how those surgical interventions differ with respect to stone clearance, but no information about other outcomes that are important to patients, which includes the patient experience before and after surgery,” said Tasian, whose research on stone disease in all ages has been published extensively.

To learn more about optimal treatment for pediatric patients with stones, Tasian started and directs the Pediatric KIDney Stone (PKIDS) Care Improvement Network. The group of 25 US health centers is conducting a Patient-Centered Outcomes Research Institute (PCORI)-funded comparative effectiveness trial of ureteroscopy, shockwave lithotripsy, and percutaneous nephrolithotomy (NCT04285658).

“One of the key components of the network is called the PKIDS Patient and Family Partners. This is a group of engaged adolescents, all of whom have stone disease, as well as caregivers and family members,” he said. “We started by asking the question, ‘What are the outcomes that are important to you?’”

So far, Tasian and colleagues have learned that pediatric patients with stones strongly identify with how the stone disease experience affects them psychologically, as well as their peer relationships and sleep. Patients also ranked anxiety high on the list.

Quality-of-life aspects include patients’ emotions and social functioning, how they feel, and how that impacts their daily lives. There are various instruments that broadly measure quality of life, but only 1 is stone-specific: the Wisconsin Stone Quality of Life Questionnaire (WISQOL, 

), developed by Penniston and Stephen Y. Nakada, MD, FACS, FRCS (Glasg), chairman of the Department of Urology and The David T. Uehling Chair in Urology at the University of Wisconsin School of Medicine and Public Health. Penniston was awarded an American Urological Association (AUA) Research Scholar Award to help fund the development of WISQOL, which has since been translated into 7 different languages.

“To study the WISQOL further, we formed a consortium in 2014, and today 16 academic centers are involved in [it]. Our consortium has published 2 dozen papers and there are more in manuscript form. We’re learning a ton,” Penniston said.

WISQOL helps identify treatments that are aligned with patients’ goals. Although it can be used in the clinic, the tool is mostly used in research. Penniston and colleagues continue to study how to make the tool more user friendly for urology clinics, including determining how which findings are and are not clinically relevant.

There are other instruments that urologists can use to gauge patients’ quality of life. The widely used Short Form 36 (SF-36) is a generic health-related quality-of-life survey. The Patient-Reported Outcomes Measurement Information System (PROMIS, 

) is another helpful tool. The National Institutes of Health-funded PROMIS ascertains outcomes in different health domains, such as physical, mental, and social health. PROMIS instruments can be applied across populations, including those with stone disease, according to Tasian.

Ziemba said the downside of the current WISQOL is its length. The SF-36, although not designed specifically for urology or kidney stones, lets urologists know if patients are doing better in terms of their mental and physical outcomes. The customizable PROMIS measures, according to Ziemba, are short forms that can take as little as 2 minutes to complete and can inform urologists about patients’ pain and how it might interfere with daily activities.

Although instruments are helpful, they are not always necessary.

“The goals of urologists and stone patients should be aligned, but it comes down to how well the patients are informed and how realistic their expectations are. Hence, they should not just have a verbal chat but should also be given written procedural literature and access to national urology association websites, such as AUA, which also has patient-centered information and information about different conditions and procedures,” said Bhaskar K. Somani, MRCS, FEBU, DM, FFSTEd, FRCS (Urol), a professor and consultant urological surgeon at University Hospital Southampton NHS Trust in Southampton, United Kingdom.

Setting realistic expectations includes addressing quality-of-life issues that patients often ask about, such as what treatments are going to be like, how long they will be out of work or school, and how stone disease and treatment might impact their lives in the long term, according to Tasian.

Patients who are worried about pain, for example, should know that there is no such thing as pain-free surgery.

“But you can provide reasonable expectations and safely try to reduce the amount [of pain] or at least the pain interference that one experiences,” he said.

Getting a sense for how a treatment might impact quality of life starts with asking the question, according to Tasian.

“It necessitates getting out of the framework that we’ve had in surgery for so long of clinicians’ defining outcomes. It takes…humility to ask the question [of] patients: ‘What is important to you?’” he explained.

Quality-of-life data can help guide treatment.

What patients with stones want and why it matters

Over the past 10 years, there has been a rapid evolution in the evaluation and diagnosis of prostate cancer. Previously, prostate cancer detection relied on a digital rectal exam and systematic biopsy using transrectal ultrasound guidance. Improved prostate cancer detection was obtained by increasing the number of cores taken during the biopsy. However, advancements in prostate imaging with multiparametric magnetic resonance imaging (mpMRI) has changed the prostate imaging paradigm. Tumors that were previously only detected microscopically can be detected radiographically prior to biopsy. This has resulted in the adoption of image fusion technology to combine the MRI imaging with real-time ultrasound imaging during the prostate biopsy procedure.

Acknowledging the expanded role of prostate mpMRI in the detection and treatment of prostate cancer, the American Urological Association (AUA) provided a policy statement in 2017 regarding mpMRI.

 At the time the statement was published, there were sufficient data to support prostate MRI in patients with a prior negative biopsy and an ongoing concern for cancer. However, insufficient data were available to support routine prostate MRIs as preparation for a patient’s initial biopsy. New data evaluating mpMRI prior to biopsy have shown a potential benefit for patients undergoing their first biopsy. The AUA recently released an updated standard operating procedure (SOP) with a recommendation to consider mpMRI for all men with no prior biopsy who are considering a prostate biopsy.

 In this article, we will discuss the updated SOP for prostate imaging and consider additional recent reports on prostate biopsy in light of this rapidly changing field.

The added value of prostate imaging is dependent on the combination of image quality, reader experience, and engagement from the urologist performing the biopsy. The AUA SOP suggests that optimal imaging is provided by a 3.0 Tesla (T) magnet with a surface coil. Some centers with older 1.5 T machines may obtain acceptable imaging using an endorectal coil, whereas those with newer 1.5 T scanners obtain adequate images without the coil. Both anatomical and functional images should be acquired, with target lesions identified and marked by the radiologist using the PI-RADS v2.1 criteria.

After identification of the potential target lesion, the urologist can determine the best approach to obtain adequate samples for diagnosis. Having the capability to conduct both transrectal and transperineal biopsy provides the best opportunity to sample the target regardless of location 

. Samples obtained during transrectal biopsy typically include a portion of both the peripheral zone and the transition zone. However, sampling apical areas of the prostate is more difficult from the transrectal approach, given the needle angle and potential for patient discomfort. Conversely, the transperineal biopsy provides cores with varying amounts of peripheral and transition zone, depending on the location of the biopsy. The needle orientation gives the advantage of obtaining cores from the apex of the prostate. In patients with a prior negative biopsy, apical lesions identified on mpMRI may be sampled using the transperineal approach to diagnose occult cancer that may have been missed on a prior transrectal biopsy 

Advancements in prostate cancer detection and opportunities for image-guided biopsy have resulted in some clinicians advocating against systematic biopsies as an unnecessary addition to the fusion-guided targeted biopsy. Arguments for avoiding systematic biopsy include a reduction in detecting clinically insignificant cancer and lessening the risk for adverse effects such as infection or bleeding. There might even be the potential to avoid biopsy altogether in patients who have no target lesion on the MRI.

However, a recent report from the TRIO study group cautioned against the omission of systematic biopsies.

 In this study, which included men who were biopsy naive, had a prior negative biopsy, and were on active surveillance, 2103 participants with an MRI-visible lesion underwent both systematic and targeted biopsy. Of those, 408 underwent prostatectomy. The investigators found that the combination of systematic and targeted biopsy resulted in the highest detection of clinically significant prostate cancer and prevented the misclassification of 8.8% of significant cancers missed on targeted biopsy alone. Further, when considering patients who went on to radical prostatectomy, the investigators found that the combination of systematic and targeted biopsy reduced pathologic upgrading to only 3.5% of patients.

Findings from additional retrospective studies have confirmed that detection of clinically significant cancer is optimized by the combination of systematic and targeted biopsies. In a study of over 500 patients with targetable lesions undergoing fusion biopsy, the detection of prostate cancer was significantly higher when combining systematic and fusion biopsy.

 When considering only those in whom clinically significant cancer was identified, the authors found that the combination of systematic and targeted biopsy resulted in a 6% improvement in cancer detection. Had the systematic biopsy been omitted, 29 of 185 patients (16%) with clinically significant cancer would have been misclassified. The authors concluded that standard systematic biopsy should be routinely included at the time of fusion biopsy to avoid missing a significant number of patients harboring occult clinically significant prostate cancer.

Although MRI fusion biopsy has clearly been shown to improve prostate cancer detection, in some areas the implementation of prostate mpMRI has been hampered by the high costs of imaging systems and fusion devices. Many urologists can defray the financial burden by partnering with a hospital or imaging center. However, even when adequate imaging systems are in place, some urologists face a reluctance by radiologists to read mpMRI images and mark potential target lesions. The cost and complexities of mpMRI and fusion biopsy systems has led to the increased consideration of alternative imaging modalities. Advances in ultrasound technology have produced new, high-resolution micro-ultrasound devices capable of operating at much higher frequencies (29MHz) than standard ultrasound devices. This higher frequency provides significant improvement in ultrasound image resolution, with some devices achieving a resolution of up to 70 μm. The improved resolution means that micro-ultrasound is better able to visualize the ductal anatomy and cell density, which, like mpMRI, could represent changes associated with prostate cancer.

A recent study compared the accuracy of micro-ultrasound directed prostate biopsy to MRI-fusion prostate biopsy.

 The study included 104 patients with known lesions on mpMRI who underwent a micro-ultrasound targeted biopsy followed by an MRI-fusion targeted and 12-core systematic biopsy. The micro-ultrasound targeted biopsy was found to have a sensitivity of 94% for the detection of clinically significant prostate cancer, with 33/35 cases successfully identified. The specificity of micro-ultrasound was 28% with a positive predictive value of 40%. There was general concordance of targets between micro-ultrasound and mpMRI lesions. However, micro-ultrasound detected clinically significant cancer in 3 discordant cases whereas mpMRI detected clinically significant cancer in 4 discordant cases. The authors concluded that advanced prostate ultrasound may provide a new option for the detection of clinically significant prostate cancer.

The last decade has seen a back-and-forth swing in enthusiasm for prostate cancer screening and diagnosis. The era of early detection with prostate-specific antigen (PSA) screening and aggressive treatment of low-risk disease ended with a movement recommending against PSA testing. However, some believe that the resulting wave of high-risk and advanced prostate cancer could be attributed to delays in diagnosis that developed from these recommendations. Advances in prostate imaging have provided a new opportunity to identify prostate cancer early on and provide effective treatment.

A fear that we may be repeating the past sins of overdiagnosis has started to gain momentum, but it is important to consider the alternative perspective. We know that, historically, prostate cancer was a frequent cause of cancer mortality in men. Although recent advances in the treatment of advanced prostate cancer have produced significant survival gains, improved detection could prevent the development of advanced disease while allowing for treatments that preserve quality of life. Advances in prostate imaging have led to the consideration of focal therapy for men with identifiable lesions who are willing to consider novel treatments that are less likely to cause changes in urinary and sexual function.

Advanced prostate imaging and improvements in prostate biopsy techniques have resulted in a new paradigm of prostate cancer screening and diagnosis. Men with elevated PSA are now considered for up-front prostate imaging with mpMRI. Those with no lesion undergo a 12-core systematic biopsy whereas those with a lesion undergo targeted sampling of the index lesion. Men with a negative biopsy have the assurance that occult clinically cancer is not present. Additional genomic testing is available based on the urologist’s preference. Men with low-risk disease can be offered active surveillance with a future confirmatory biopsy following a repeat MRI. The era of repeat serial biopsy has been replaced by prostate imaging. It is true that although image-guided prostate biopsy may increase the diagnosis of some low-risk cancers, it also provides improved opportunities for surveillance.

Unfortunately, some men will be diagnosed with clinically significant prostate cancer. For those with intermediate- and high-risk disease, prostate imaging can be useful for staging and treatment planning. This can be particularly helpful for the evaluation of nerve sparing and bladder neck anatomy. Although the potential impact of micro-ultrasound remains unknown, continued improvements in prostate imaging should further optimize prostate cancer detection, reduce treatment morbidity, and improve outcomes of prostate cancer treatment.

is assistant professor of urologic oncology at the University of Oklahoma, Oklahoma City.

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Advanced imaging and improvements in biopsy techniques usher in a new paradigm for screening and diagnosis.

Vol 48 No 10