Key takeaways from this episode

• CMS's MLN article did not extend the Medicare claims hold; it clarified that MACs were only asked to hold claims for services whose COVID-era support expired, mainly telehealth and a few hospital and ambulatory services. Other traditional Medicare claims can be processed, and with the 10-day hold now past, held payments should begin to resume.
• Medicare Advantage and commercial telehealth coverage is not affected by the shutdown; only traditional Medicare telehealth is. A Medicare Advantage plan could elect to stop covering telehealth because it is no longer a mandatory benefit, but turning it off and back on is not easy and Mark considers it unlikely.
• To confirm a Medicare Advantage plan is still paying telehealth, check the payer website and bulletins first, then submit a few claims and watch them process before building volume. It is too early to see denials: October 1 was only 11 business days ago and most Medicare Advantage plans take 20 to 30 days to process, versus about 10 for Medicare.
• Removing a bladder stone through the laparoscope during a robotic simple (55867) or radical (55866) prostatectomy is separately reportable with 51999, unlisted laparoscopic procedure on the bladder. 51050 is not bundled with either code in the NCCI matrix, but neither prostatectomy descriptor includes a cystotomy, so the stone removal is separate work; 51050 itself fits only if the bladder was separately opened, and a cystoscopic litholapaxy or grasper removal before or after the prostatectomy would be coded differently.
• Urocuff should not be billed as 51729 because the device does not produce a true urethral pressure profile, and UnitedHealthcare's audit was right on that point. PRS has long recommended 51728 with modifier 52 or, for some payers, 55899 or 53899; a documented leak point pressure supported the UPP under the old structure but does not now.
• United's denial letter suggested 51725, which contradicts its own omnibus code policy requiring 55899 on the commercial side, so submit corrected claims with 55899. The separately billed uroflow (51741) was denied inappropriately and should be appealed, and abdominal pressure add-on 51797 is supported when separately measured, though it flows through 55899 with only some payers.
• For Medicare Advantage, United follows the MAC's LCDs and LCAs; Novitas and CGS have LCAs stating 55899 is appropriate for Urocuff natural fill, billed with 51741 and 51797. Payer websites, not appeal responses, are the reliable source for these rules, and Urocuff and urodynamics coding guidance is on the PRS Hub at prsnetwork.com/urocuff and prsnetwork.com/urodynamics.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 263, recorded October 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Government shutdown update and the Medicare claims hold

[00:00] Scott Painter: On this episode: the latest on the government shutdown, coding for the removal of a bladder stone with a laparoscopic prostatectomy, and Urocuff coding revisited. Stay tuned. Welcome to episode 263 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Let's go ahead and get started. Government shutdown: what's the very latest? As we're recording this, today's date is October 17th. Where are we, Mark?

[01:00] Mark Painter: Right now there are a couple of things out there. Number one, we're still shut down, obviously. They have not come to an agreement on how to solve the issues at hand. Basically, the impasse is the Democrats not wanting to see the ACA subsidies go away, and the Republicans wanting to kick the can down the road until the middle of November. Those are the choices they're voting on routinely in the Senate. They've voted seven or eight times, it hasn't passed, so it's dragged back to the drawing board. It does look like the Republicans may make a move to figure out how to pay certain federal government employees and the military; that should come up next week. That doesn't bode well for any longer-term solution, but that may be the stopgap push they go through next. We'll see what happens there.

On the other side, I got a lot of questions recently. Medicare put out an MLN article relating to the hold on Medicare claims, and that article was confusing and helpful at the same time. The way the article was worded, it really appeared, and this was the question I got, that they might be extending the Medicare hold on claims. But after you really read through it and dissected it, it was actually CMS clarifying that they only requested a hold on those claims that had seen an expiration of support. That would really focus on telehealth and a few things in the hospital and ambulatory services that were all set up for COVID. The way CMS actually directed the MACs, according to a further read on all of this, was that they could still process claims that weren't affected by the expiration of the continuing resolution that had kept the government open last time and extended healthcare coverage. So you may have been getting some Medicare payments, but now we are 10 days out, so those should start to resume if you did see a hold, and we did see a lot of folks with a hold. That's what they clarified. I'm not sure the MACs actually understood that.

The other thing the MLN article reiterated was something we've been telling you: Medicare Advantage plans are not affected by the expiration of the COVID rules for telehealth. That means your Medicare Advantage plans, as we've stated before, can still cover telehealth, and many of them are, from what we're seeing. So you want to make sure you build your strategy around that and understand what your Medicare Advantage plans are going to do. Many of them probably won't turn those services off, because they're expecting Medicare to turn them back on, if you will, as far as that coverage. As you're looking at telehealth and those options, it is going to be payer-specific, but I want to reiterate, as did this MLN article, that telehealth for Medicare Advantage plans and commercial plans is not affected by the government shutdown. Only traditional Medicare telehealth is affected.

Medicare Advantage plans and telehealth during the shutdown

Scott: Could a Medicare Advantage plan decide not to pay for telehealth during this time?

[05:00] Mark: They could, because it is no longer a covered benefit in Medicare, so they could make the election not to cover telehealth. But if they were covering it before, toggling it on and off is not that easy. I find it unlikely, but it is possible.

Scott: And it's not mandatory?

Mark: It's not mandatory.

Scott: If you wanted to make sure, would you just test one or two, or just assume it's going to go through, or would you call them? What's your recommendation?

[06:00] Mark: Step one, check the payer website. See what their bulletins are, and look at coverage. Step two, yes, try a few and see if they process. As you go through that, it never hurts to call, although it is painful, so maybe it does hurt to call, but only in time and effort. So check the website and the bulletins first, then try a few. If you were getting paid before, my lean would be to assume yes, but I would also say you probably don't want to get too far strung out and end up with a bunch of denials, so it is something to watch. If the bulletin says go ahead, then go ahead. Ray, questions, comments?

Dr. Ray Painter: Mark, in your group, have you noticed any particular Medicare Advantage plan that has stopped paying?

[07:00] Mark: It's a little soon. Remember, October 1st was only 17 days ago, and we had a federal holiday on Monday, so it's 17 calendar days, but it's really only been 11 business days. A lot of our Medicare Advantage plans don't process that quickly. They average 20 days at the fast end. Medicare's usually the fastest, around 10. We may have a couple of commercial payers that pay that quickly, but not many. It's more like 20 days out or 30 days out. So I can't answer that, because there just hasn't been enough time.

Bladder stone removal during a laparoscopic prostatectomy

[08:00] Scott: All right, let's move on to our first question. We had a question come in from Theresa. Theresa said, "I need clarification billing CPT 51050 and 55867 or 55866. Can we bill both codes together, and if denied, should we appeal? Or is this correct?" And she's asking us if this is correct, and the quote is: "Billing an open 51050 along with the robotic 55867 is still considered a form of unbundling. The CPT code 55867 includes all of the steps necessary to perform the surgery. The surgeon already has to cut through the bladder on his way to the prostate with a robotic arm. Therefore, removing the stone that is in the bladder is considered incidental to the larger surgery. The surgeon didn't have to perform a second procedure. It was all in the actions of the one necessary way to reach the prostate." Okay. What do you have here, Mark? Where's that coming from?

Mark: A couple of different things to start with. Number one, if you put 51050 and 55867 or 55866 into the bundling matrix, you'll see they're not bundled. So that may be why she's asking this question, given the way she understands the surgery.

[09:00] Scott: Should we read those two codes, or three codes, for everybody who hasn't memorized the stone codes? The 51050 description is cystotomy or cystolithotomy with removal of calculus, without vesical neck resection. The 55867 is laparoscopic surgical prostatectomy, simple subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), includes robotic assistance, when performed. And the 55866 is laparoscopic surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.

[11:00] Mark: Thanks, Scott. Those codes are not bundled, which is probably why she's asking whether they are still bundled based on the actual procedure itself. Ultimately, when we read through operative reports for robotic prostatectomies, there is a section of the urethra, and you heard in the description that a urethrotomy is included, but you'll notice there's nothing in that description about a cystotomy. Typically, although you are going to have easier access with your laparoscope into the bladder, you're not actually opening the bladder to do any work within the bladder when a standard simple prostatectomy or a radical prostatectomy is performed. So I do think there is separate effort for that removal of the stone that should be reported.

Now, I'm assuming, and we'd have to look through the note, but I'm assuming from the way she asked the question that the stone was removed while the laparoscopic procedure was in process: because of either the incision in the urethra or the removal of a portion of the urethra, they had access to the bladder and were able to use the laparoscope to remove the stone. In that case, I would recommend adding code 51999, which is unlisted laparoscopic surgery on the bladder. That would make the most sense, without having read the operative note, based on my understanding of the procedure and how it's done most frequently now. Certainly there are other ways to do it. You could remove the scope, go back in, open up the bladder and bill the 51050, but that would be a separate work effort. And of course the other way it could be done is either prior to the prostatectomy or after the repair is done: a cystoscope could be used to remove the stone through litholapaxy or just a grasper and removal of the stone. You'd have to go through the full operative note to understand it, but making the assumption, based on the way she asked the question, that the laparoscope was used to remove the stone, my recommendation would be to report the 51999, because that access to the bladder, and typically the entrance into the bladder, is not really a part of most simple or radical prostatectomies. Ray, comments?

Scott: Questions?

Ray: No, I think Mark nailed it.

UnitedHealthcare urodynamics audit and Urocuff coding revisited

[14:00] Scott: Agreed. Okay, let's move on to our final topic, our final question. We had a question come in from Kathy, and we got some information on the question, but Mark's going to have to give us a little more color, as he had a conversation with Kathy. She said, "I'm a certified coder in Georgia and have a question about a recent audit that our practice had with UnitedHealthcare in regards to urodynamic services, and I was wondering if we could get assistance with that, because we don't agree with what they're saying." So Mark, what was this audit, and what do you have as far as recommending to everybody out there? What's going on?

[15:00] Mark: The issue is that the code originally billed for a Urocuff was 51729. They do provide the reports here, and as many of you know, the bladder voiding pressure is measured with the cuff. We've been recommending over the years that Urocuff is typically billed with 51728 with a 52 modifier, and for some payers we would look at 55899 or 53899 as options to report the use of the Urocuff, because the CMG portion of this, the cystometrogram, is really not the same with the Urocuff. It gives you a lot of bladder information, but it is not the same as a standard urodynamic evaluation relative to the 51728. Now, 51729, which was used in this instance, includes not only the bladder voiding pressure but the urethral pressure profile study and the CMG. So we can certainly understand UnitedHealthcare's position on the CMG portion of the information. That's something we have seen for years, and that's why we've recommended that particular coding.

Now, there is a lot of information provided by the Urocuff, and one of the things they have documented in their cases is a leak point pressure, which in the old coding structure did support the UPP, or the 51729. But we do not actually have a good urethral pressure profile in many of these cases, because the UPP is really trying to measure the internal urethral pressure profile. So I wouldn't recommend typically using the 51729 with the Urocuff. I am going to have some conversations with the manufacturer, SRS, who works with the Urocuff, to see if they've done any additional development around the UPP study as part of this. But my understanding of what was done in the past versus where they are now, and looking at the documentation, is that we didn't get a true urethral pressure profile, so the 51729 would be inappropriate, as UnitedHealthcare said.

But United actually came back in their denial letter recommending a 51725, which is counter to their own omnibus coding rules. This is a circumstance where United, on the commercial side, has generally followed the directive to require the 55899. So I'm going to recommend to Kathy that these claims be submitted as corrected claims under the 55899. They are billing the uroflow, the 51741, as a separate entity, so that one should be covered, and I believe our friends at United denied that inappropriately, so we can push back on that particular issue. And then the 51797 is the abdominal pressure, which we do have the results for in the note. The 51797 requires a separate measurement and is an add-on to the Urocuff procedure. That's where the 55899 may provide some problems, as some of the payers have 51797 as an add-on code to the 51729 or the 51728. Hopefully the switch to 55899 would actually allow the 51797. It's not a standalone code; it has to be an add-on code, and 55899 is one that could potentially allow the 51797 to flow through, and it does with some of the payers. United may be problematic there, but this is one of those areas where you absolutely want to check the payer websites. It took a few clicks to get to this.

And then for your Medicare Advantage plans, United does follow any LCDs or LCAs that are published for your area, for your MAC. So if you're within Novitas or CGS, those are groups that have specific LCAs that indicate the 55899 is appropriate for the natural fill that is part of Urocuff, and that the 51741 could be provided at the same time, as could the 51797. It's definitely one of those areas where, because we don't have an exact code, we've got to watch our payer websites and we've got to watch Medicare. What Medicare does is probably going to drive your Medicare Advantage plans, which of course tends to influence how they handle commercials in the same area.

Scott: Ray, comments, thoughts?

Ray: No, nothing to add.

Hub resources, sponsor and final thoughts

[21:00] Scott: All right. I will also add that there is information on the PRS Coding and Reimbursement Hub. If you go to prsnetwork.com/urocuff, there's information on the coding and billing of Urocuff. Also, if you go to prsnetwork.com/urodynamics, there's a more in-depth discussion on coding and billing for urodynamics. That's what we have for you today. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. We want to thank you all for listening. Let's get some final thoughts and we'll end this episode here. Mark?

[22:00] Mark: Final thoughts overall today: we've actually referenced in two of our answers the importance of checking payer websites, bulletins and coverage issues. It does take a little bit of searching sometimes to dig your way down into the actual guidance the various payers have, and they may have additional restrictions. So you want to dive down into those websites and get familiar with how to search them, for both telehealth and for the natural fill uroflow of Urocuff. You want to make sure you can navigate those websites to see if they provide some additional guidance, and you definitely want to make sure you're doing that before you start appealing and pushing things through the system. As you get further into the process, you'll get responses that are based on the way you coded, which may not, and actually rarely, guide you to the right answer. The other side of this that I'll add to the mix is that the way United actually reviewed and responded to the appeals and the review of the medical records wasn't even consistent with their own policy, which is common. So again, you want to be able to leverage their rules and their instructions as you talk through or deal with these payer organizations. And then relative to the shutdown, we keep waiting and hoping, and we'll see where that goes. We'll keep you posted.

Scott: Ray, final thoughts?

Ray: Well, the discussion today just continues to point out the importance of the details in the surgical procedure: to know exactly where the access is and what was done at that procedure is ultimately very important. Not just the fact that there might have been extra work done, but how it was done. So you need to dissect those operative reports and be sure you understand the anatomy before you can code correctly.

[24:00] Scott: Right. Very important. That's all we have for you today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

Scott: And billing. Next time we'll get it.

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