Jonathan Rubenstein, MD

"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.

"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.

Proper coding for percutaneous nephrolithotomy includes code 50081.

Proposed rule includes incorporation of controversial E/M code.

"CPT codes 50080 and 50081 describe the antegrade approach to stone removal requiring lithotripsy through a nephrostomy tract, with 50080 being reported for stones less than 2 cm in size in a single location, whereas 50081 would be reported for large or complex stones, stones in multiple locations, or stones in the ureter (such as in the example provided)," write Jonathan Rubenstein, MD, and Mark Painter.

Telehealth is here to stay. Lean into the technology as the new line of business that it is.

Correct code selection depends on whether procedure is simple or complex.

"Although payers are supposed to adopt CPT instructions, we unfortunately do not have a system that contractually binds payers to follow CPT instructions verbatim," write Jonathan Rubenstein, MD, and Mark Painter.

Modifier -25 is defined as a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Patient communication is key when implementing new policy.

"We will add this question to the continuing saga and changing world of CPT coding," write Jonathan Rubenstein, MD, and Mark Painter.

One factor is whether dissection was performed for staging or for therapeutic purposes.

"PCM codes require the practitioner to develop a disease-specific care plan, to obtain a patient’s verbal or written consent, and to educate the patient on PCM," write Jonathan Rubenstein, MD, and Mark Painter.

"We once again note that even success in the efforts to avoid any payment decreases will be a failure in the long run as overhead continues to rise against flat reimbursement," write Jonathan Rubenstein, MD, and Mark Painter.