Key takeaways from this episode

• Promaxo-guided prostate biopsies should be reported with the new in-bore MRI/CT-guided codes 55713 and 55714. After conversations with the AUA, PRS is comfortable that the codes were intended to cover any true MRI-guided biopsy and that "in-bore" was added only to distinguish them from fusion biopsy; push back on any payer that reads the descriptor more narrowly.
• Use 55713 for sextant plus the first targeted lesion, 55714 for a targeted lesion only, and add 55715 for each additional targeted lesion. The add-on works the same way it does with the fusion biopsy codes, and all of these are zero-day globals.
• 55713 pays $764.88 non-facility, $185.71 facility, $2,729.66 in the ASC and $5,477.93 HOPD. 55714 pays $746.18 non-facility and $169.01 facility with the same ASC and HOPD rates, versus transperineal 55712 at $607.23 non-facility, $157.99 facility, $1,723.02 ASC and $3,601.33 HOPD.
• Check eligibility three days before and again one day before every January visit, and read the full response. Benefit plans have rolled over, exchange patients may have unpaid or canceled policies because ACA subsidies were not renewed, and a Medicare Advantage primary can sit below the traditional Medicare line in the eligibility response.
• Collect the deductible and co-pay before the service, erring on the side of over-collection. Set a standard up-front amount if your system cannot estimate patient responsibility, then monitor credits and refund or apply them within 30 to 60 days so a large credit balance never builds up.
• When a patient says "just run it through my insurance," show them the deductible printed on their card. Explain that a plan with, say, a $4,000 deductible will not pay for most of today's services until that amount is met; only patients who genuinely understand their coverage should be allowed to bypass up-front payment.
• Payer portals such as Availity still lack the 2026 biopsy codes. Consider getting prior authorization under deleted code 55700 and re-authorizing when the biopsy is scheduled, and if claims deny as "code not valid," wait a week and resubmit.
• Re-copy every patient's insurance card at the start of the year, including Medicare patients. Medicare Advantage plans are marketed as add-on benefits rather than a change in coverage, so patients often do not know their insurance has changed.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 272, recorded January 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Promaxo and the MRI-guided biopsy codes 55713 and 55714

[00:00] Scott Painter: On this episode: an update on Promaxo and the new prostate biopsy codes, and deductibles and collection logistics. Stay tuned. Welcome to episode 272 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Mark has an update for us on Promaxo and wants to share a little more information about that. The other thing we're going to cover is that it's deductible season, so we want to cover deductibles and the collection logistics. Let's dive right in. Mark, what have you learned about Promaxo? What new information do you have for us?

[01:00] Mark Painter: In episode 269, we discussed the potential of using codes 55713 and 55714 for the Promaxo, and we had a couple of concerns relative to the wording in the CPT code that mentioned in-bore MRI. The Promaxo is portable, a smaller unit of an MRI, and that's where that concern came from. But the reality is those codes are for MRI-guided or CT-guided biopsy. I had some conversations with folks at the AUA and talked to them about what the intent of the code really was, and whether or not a smaller MRI like Promaxo, a small portable MRI, would actually match the definition of that code. Essentially the conclusion overall is that indeed that was the intention of the code: to capture the description related to MRI-guided biopsy, and in fact the Promaxo is an MRI that can be used to guide biopsies.

So if you are using a Promaxo to perform a biopsy, remember that 55713 is for the sextant plus the first targeted lesion, and 55714 is for the targeted lesion. Then, of course, if you do a second targeted lesion using MRI guidance, you would use 55715, just like you would with the fusion biopsy codes. I'm now far more comfortable stating that that was the intention of the codes, and that's indeed what we are going to recommend that you use. Now, there may be some payer interpretations that are different, but I would go back to that payer and really focus on the fact that this is a true MRI-guided biopsy. The "in-bore" was added essentially to differentiate the fusion biopsy from an MRI- or CT-guided biopsy.

Payment rates and code descriptors

[04:00] Scott: Yes. Just as a reference, I can read off the payments for 55713 and 55714, both facility and non-facility, and also the ASC and HOPD, in comparison to some of the other codes. 55713 in the non-facility setting pays $764.88, in the facility it pays $185.71, in the ASC it pays $2,729.66, and the HOPD is $5,477.93. As a comparison, the transperineal code, 55712, pays $607.23 non-facility and $157.99 facility. In the ASC it's $1,723.02, and the HOPD is $3,601.33. So those are the amounts for 55713. The 55714 pays just about the same: non-facility pays $746.18, and in the facility it pays $169.01, and the ASC and HOPD are the same for 55713 and 55714. And those are still zero-day globals as well. Okay, Ray, any questions on Promaxo?

Dr. Ray Painter: No, I think you've made it very clear. I wonder if it would be of value for you to read the definition of the codes for those who are not near their computers.

[06:00] Scott: That makes a lot of sense. 55713 is biopsy, prostate, in-bore CT or MRI guided (i.e., sextant) with biopsy of additional targeted lesion or lesions, first targeted lesion. And 55714 is biopsy of the prostate, in-bore CT or MRI guided, targeted lesion or lesions only, first targeted lesion. So those are the two descriptions.

Mark: Okay.

Scott: Let's move on to the next topic. Thanks for getting that clarified. The next topic is deductibles. We're in deductible season. What do people need to know about deductibles and collection logistics?

Deductible season: verify eligibility and insurance changes

[07:00] Mark: Well, it's January. That's what everybody needs to know. Happy New Year, as you're dealing with everything else we're dealing with, including new codes that aren't added, prior authorizations blocked, claims being blocked, payments being delayed. We also have the beginning of most people's insurance benefits, which means nobody, or very few people, has met their deductible. So it's very important, as part of the overall process of checking patients in, to find out what their co-pays and deductibles are, because those have probably changed with the benefit plan rollover from last year to the new year.

The other thing you have to consider as you check all of this is that your patients' insurance is more likely at this time of year to have changed. Then we add one other layer on top of everything: we had the discussion around the ACA subsidies. We had a lot of patients go out and purchase coverage through the exchange programs, hoping that perhaps Congress would come through with a subsidy to help offset the cost of their premiums. Of course, that hasn't happened yet. That means you're also going to have a bunch of patients who may have signed up for health insurance and actually haven't paid for it, so they may have a canceled insurance policy. You're also going to have some folks who realized they couldn't pay for the benefit program and have gone out and tried to find another one, so they may not have the right insurance card. This time of year really is a front-office-focused time of year. Your demographics and intake people need to get copies of everyone's ID. Now, we say that year round, and it's true year round; you want to check those patients' IDs relatively frequently.

We're going to have issues related to Medicaid across the country this year. We're still having the Medicare Advantage bounce issue. Patients are moving, patients are not paying. There are a lot of things happening that are completely out of the control of the physician office that are making your life difficult and the pathway to payment far more difficult. So that upfront process really needs to be focused on this time of year. You need to give your office staff plenty of time to get that done. I know there are folks out there experimenting with AI to try and get all of this information done. Double-check those processes, procedures and protocols. Be extra diligent on checking eligibility before every visit. You might want to check it three days before, and then again one day before. Make sure you read through the eligibility response and discover exactly what plan they have. Remember, with Medicare Advantage plans, the patients will be eligible for Medicare, so if you don't look far enough into the eligibility response, you may not see, down below, that they actually have Medicare Advantage as their primary. Of course, there was a big push to move patients around in their Medicare Advantage programs, and some folks were looking at switching their Part D coverage.

So you've really got to be diligent. You really have to pay attention and dig deep. Put that extra step in there, put your protocols in, and remember that more work is more work, and that translates to additional pressure and additional opportunities for mistakes for that front office staff. As much as you can, get that done before the patient comes in, make sure that's part of the protocol, and double-check it when they get there. All of that has to be part of the January approach to healthcare in the United States.

Collect up front and manage credits

Scott: Ray, comments, questions?

Ray: Mark, you may have mentioned it and I may have missed it, but it's also a time when you have to collect up front, because now the insurance is not going to pay during the deductible period.

[13:00] Mark: That is a good point. I did mention collecting the deductibles, but you said it far better. The deductible not having been met makes the payment that's coming back, in addition to the co-payment, part of what the patient needs to pay. So if you can dive into the process and figure out what those collections need to be, you want to make that collection. There's always a discussion we have with folks about over-collecting versus under-collecting. My opinion has always been that you're better off with an estimate that covers your costs for the services provided, and writing refunds to your patients. A lot of these patients are going to be coming back during the year. They're also going to be seeing other physicians, and their deductible may be met by seeing those other physicians. I don't think there's any way to avoid credits if you are collecting appropriately for those visits, meaning prior to the visit.

If you don't have the sophistication in your practice management system to know what the dollars should be, could you set a standard amount for the initial deduction? Yes, you can. You do potentially have to refund those patients, or at least the balance of that credit needs to be expected to be used within 30 to 60 days. So you want to make sure you're monitoring those credits, and hopefully you're not ending up with what we see with a lot of folks, and that's a big credit issue that needs to be solved in one fell swoop, with a relocation of folks to write checks and refunds to patients. Stay on top of that as much as you can. Develop a program of money in and money that has to go out, and develop your policies relative to those deductibles. The practices we hear from frequently that are having trouble with cash flow are the ones that don't collect prior. Now, you have some patients you've known for years and you know they're going to pay their bills; those may not be the ones you need to collect from. But a standardized policy, erring on the side of collection up front, is in my opinion the best policy to have.

Answering "just run it through my insurance"

[16:00] Scott: I think you've said it best in our seminar: the motivation for paying is much greater when they have a problem or they haven't received the service yet, versus after. That changes the motivation for getting that paid tremendously, so that's something to consider when you're putting together your protocols. The other thing I'll ask you is, what's a good response to the patients who say, oh, let's run it through my insurance, let's see what that actually comes out to be. We don't know what insurance is going to pay and what I owe, so let's let it run first and then I'll pay it in the end.

[17:00] Mark: Those are tough. First of all, the question usually comes up in the form of, I have insurance, I shouldn't have to pay. Explaining to the patient what the co-pay is is one thing, and the other part is explaining the deductible. The easiest I've seen, and it is more time out of the schedule, is usually on the card you see for the patient: they have a deductible number printed on the card, or now I guess we have them all electronically. If you can show the patient that this number is a deductible, which means that number needs to be met before insurance begins to pay, that would be where I would go first. Try to educate them and say, hey, you bought a plan that has a $4,000 deductible, so typically your insurance isn't going to pay for most service items that we're going to provide for you today until after you've paid that deductible. There definitely are screening things that might be covered under their programs, and if that patient has the knowledge of what their insurance actually covers and when, then you may be able to say, great, you clearly understand your insurance, we can let you go back. But that number of patients is going to be few and far between.

Scott: So true. All right, let's wrap this episode up. 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. All right, let's get some final thoughts. Mark, what are your final thoughts?

Final thoughts: new codes not loaded in payer portals

[19:00] Mark: One, I'm certainly glad that I've gotten a little more comfortable with the coding for MRI biopsies, not the fusion, but the MRI-guided biopsies. And just a reminder to everyone: we are noticing that a lot of the portals, like Availity and those you do prior authorizations through, as well as the payment processing tools from the payers, do not have the new codes loaded. If you really need to do the biopsy and you do need a prior authorization for that payer, you may want to consider authorizing 55700, even though that code no longer exists, so that you can then do a reauthorization when the biopsy actually occurs, as you get closer to performing the biopsy. That's one potential option out there. The other one would be to wait: if you're getting denials on the back end saying the code is not valid, the recommendation is to wait a week and resubmit. It's going to slow down your payments, and it's probably going to slow down the information that tells you the patient owes a deductible, but it is one of those processing timing issues. HIPAA requirements say they should be moving to the new codes; they just haven't made it there yet. I think a lot of that has to do with the government shutdown and the late release of all the information from CMS, but it also has to do with the fact that this is the beginning of the year. This happens every year; we just haven't had some of our high-volume procedures fall in this bucket.

Relative to deductible season, eligibility and insurance changing, again this really highlights the fact that revenue cycle management is a circle. It is a team concept, and if you don't have the front end correct, the best back end in the world is either not going to succeed or is going to have a very difficult time succeeding in collecting your money. So commit the appropriate resources, time, training and protocols to the front desk. Make sure that front desk has the support they need from everyone in the office. They are a key member of the team, and an essential part more at this part of the year than any other, but it should be a common focus of every practice to watch the front desk, make sure they've got their instructions, and make sure they are following those instructions for every single patient.

Scott: Ray, final thoughts?

[22:00] Ray: Well, as someone of Medicare age, I can tell you it is irritating to have to show your cards every year when you know nothing has changed. However, seeing all the advertisements and how good Part C Medicare is really becoming, you can't trust your patient to tell you; you have to check their cards, because they're selling the Advantage plans as not being a change in your insurance, but as just buying additional services. They're good, and I can see why so many are confused about the decisions they make. So Mark has given you good advice. Check the cards. At the beginning of the year, people have changed and don't even know they've changed.

Mark: We should add that you're barely Medicare age, right, Ray?

Ray: Yes. Not much experience there. That was last year I was talking about.

[23:00] Scott: All right, very good. Well, let's end this episode here. Thank you all for listening. Hope to see you in New Orleans at the Urology Advanced Coding and Reimbursement Seminar; there's still time to sign up. That's all we have for today. Take us out, Ray.

Ray: Happy coding, and collecting.

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