Key takeaways from this episode

• The WISeR program is built on existing national coverage determinations, so its requirements already apply to every practice, not just the six pilot states. In urology the NCDs at issue cover incontinence (two policies) and impotence (one); the six states get a voluntary prior authorization or prepayment review, but the same documentation is what RACs recoup on everywhere.
• A new Botox LCD and LCA took effect for Noridian, WPS, CGS, NGS and Palmetto, covering roughly 35 states. It is separate from WISeR, relies on post-payment rather than prepayment review, adds documentation requirements and caps dosing; the full state list is linked at prsnetwork.com/279.
• For overactive bladder and urge incontinence, the LCD requires an objective OAB scale, 12 weeks of failed conservative therapy, failed or contraindicated anticholinergics and a UA, updated and documented before every session, at 100 units per session. Overactive bladder by itself is not a covered diagnosis; the claim needs a specific incontinence code such as urge incontinence, mixed incontinence, overflow incontinence, nocturnal enuresis, post-void dribbling, continuous leakage, coital or postural incontinence, or other specified urinary incontinence.
• Neurogenic detrusor overactivity and interstitial cystitis/bladder pain syndrome are covered at 200 units per dose, following FDA labeling. Neurogenic coverage uses reflex or flaccid neuropathic bladder NOC and the neuromuscular dysfunction of bladder codes; IC coverage uses interstitial cystitis with or without hematuria and other genitourinary symptoms and signs.
• Build the NCD and LCD prerequisites (prior therapies tried or contraindicated, bladder diaries, objective scales) into your intake forms and EHR templates for every incontinence and OAB patient. Collecting it up front for everyone keeps every treatment option open and gives you the backup documentation for prepayment review or a post-payment audit.
• Know the vocabulary: RACs are contracted recovery auditors, MACs administer Medicare regionally, LCDs are local coverage determinations, and an LCA is a local coverage article that carries the coding guidance and can be issued without an LCD. MolDX and PLA codes are the parallel bundling pathway for genetic and pathology testing, and Medicare is shrinking the window for new technology from two to three years to two to three months.
• Expect more record review, not less. Medicare is hiring more auditors and using AI on medical records, and UnitedHealthcare and other payers are downcoding to pull charts, so document for both the clinical pathway and the financial pathway required to get paid.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 279, recorded March 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Why LCDs, NCDs and audits are back in focus

[00:00] Scott Painter: On this episode: audits, LCDs, NCDs, LCAs, and how they all fit together. What does it mean? What's the landscape? Stay tuned.

Welcome to episode 279 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. On today's episode: we saw a new policy, a new LCD, come out on Botox. It crept up on us, and there were some interesting things that happened with that LCD, which states and which carriers are participating in it, and which carriers are not. That got us thinking and talking about the overall structure of how these things fit together. I know we've talked about this on the podcast before, but we wanted to circle back, build that foundation again, and share how it's working currently and what's going on in the marketplace with Medicare and all the different tools they're using that are shaping their reimbursement. Mark, Ray, anything else to add on what we're trying to accomplish with this episode? We talked about it and really tried to make this a useful episode for those who are not as familiar with how everything works together. Ray, anything to add?

Dr. Ray Painter: Well, you've talked about it before, but the landscape keeps changing, so what you said before may not work. It's an alphabet soup. Stir it up, Mark.

[02:00] Mark Painter: It is an alphabet soup. What we really want to boil down in this episode is how to react to what we're seeing, in a practical way. It's one of those times when we're seeing a shift. As I mentioned while we were discussing this, the typical pattern we see with administrations is that the Democrats often focus on ramping up the search for fraud and abuse with the RACs, and then typically a Republican administration tends to roll some of that back. The last time Trump was in office, they rolled back the RACs for a while and stopped them from doing some of their additional research.

But we've gotten into a situation now where we're seeing a complete flip, in that there is a focus by this administration on fraud, waste and abuse in Medicaid and in Medicare. We've seen the very quick implementation of the WISeR program, which is based on NCDs, which is why we threw that into the introduction. National coverage determinations, specifically surrounding a number of things, but in urology, impotence and incontinence were our two targets. There are two policies on incontinence and one on impotence that we now have to deal with in the WISeR program, where they're looking at what they found through the RACs, which was a lack of compliance with those national coverage determinations.

So they moved it up the chain and put it into a voluntary prior authorization program, backed up by chart review. They were doing chart review before; it's just that they were doing it through the RACs. They only rolled it out in six states, but the reality is that the national coverage determination is national. It already applies to everybody. The only step they put in with the WISeR program was a review prior to payment for those six states, one way or another: either through a prior authorization where you have to load everything in, or through prepayment review, meaning they're going to review all your documents before they pay you. Is that going to stick to six states? Probably not. More likely that's something that rolls out quickly to other states.

Then quickly on the heels of that, we saw the introduction of the LCA and the LCD for Botox, and this did slide past us. Just to be clear, the LCD and the LCA for Botox are very separate from the WISeR program. It's a totally different issue, but it is similar in that there are some additional documentation requirements that have to be met in order to keep the money. They're not necessarily going to do the prepayment review, but they will do post-payment review, and they did put some restrictions on how much of a dose of Botox could be used.

Scott: We should probably define LCD, LCA and RAC.

Defining RACs, LCDs, LCAs and MACs

[06:00] Mark: All right. RAC: recovery audit contractors. Those are the bounty hunters that surf through Medicare data and try to find targets to recoup money from individuals who didn't follow coverage guidelines in the form of LCDs, local coverage decisions, which are focused and released by MACs for specific geographies. And then the LCA is the local coverage article, which really provides the coding guidance that's related to a local coverage decision.

Scott: Determination.

Mark: Local coverage determination.

Scott: Yes.

[07:00] Mark: Thank you. D is D. I should mention that an LCA does not require an LCD, so Medicare can issue a local coverage article without an LCD, providing guidance on how to code for something in order to get paid, typically with some additional guidance, but not at the level that a local coverage determination has. And Ray reminded me that I should address what a MAC is: a Medicare administrative contractor. MACs are the private entities contracted with CMS to administer the Medicare program in specific geographic regions. And we've seen develop, specifically around MolDX, a loose consortium of the MACs where we have our MolDX folks. Those are the MACs that are working with Palmetto in particular, well, not Palmetto anymore, but the MolDX contractor, which started in Palmetto and then was spun off into a separate company.

Scott: And we have to define MolDX, the Molecular Diagnostic Services Program. It's MOL, and then DX, like diagnosis.

MolDX, PLA codes and the push to bundle and control cost

[09:00] Mark: So MolDX was created to come up with a new way to track genetic testing primarily, and it's expanded to cover a lot of different pathology tests in particular, to bundle specific tests into a Z code. Or there is a pathway to get these into CPT called PLA, proprietary lab... I can't remember what the A is.

Scott: Proprietary laboratory analysis.

Mark: So those are specific codes for specific tests. PLA codes can be applied for and received from CPT, and they package together maybe an analysis of multiple different genes, or for PCR, multiple different tests, into a single code that has a set rate, instead of using the individual CPT codes as building blocks and stacking them up into an overall test. That's following along Medicare's pathway of bundle, bundle, bundle. They're trying to package things together so we don't have as much detail, I guess would be a way to look at it from the payment side, so we're not adding extra tests into something we don't need, and Medicare can govern its cost a little better from group to group and control who gets in. A PLA, which is CPT, can really focus on the test, whereas MolDX can focus on a specific lab. Actually, PLA codes as well can focus on specific labs and their test results and what those can and can't do, but also what those should cost from the Medicare perspective.

So again, it's alphabet soup out there. We got sidetracked on this whole consortium, and that wasn't really where I intended to go, sorry about that. But it demonstrates what the payers are trying to do in controlling cost outlays and figuring out where things should be implemented from a medical necessity standpoint, but also maybe a faster pathway to take out what we've seen in the past, which is a higher profit margin for the pioneers, who have been able to take advantage of codes stacked on top of each other, or new technology, before it actually has the parameters and the RVUs and the reimbursement set. They're essentially tightening the window. Where it used to be two to three years, now they're trying to make it two to three months before they get the coverage guidelines and the payment guidelines in. So that's the first part of this.

Now looping back to the second part, which is where we really started with the LCDs and LCAs: we're seeing Medicare dictating more of what needs to be documented, in a reproducible manner, so they can control who's getting paid and what services can be done. One of the things we've always harped on is that the payers are starting to think they can practice medicine better than physicians can. In the end, it's pushing clinical pathways down from the payer level into the practice. Of course, that doesn't let medicine evolve as fast as we would like it to, but there are still windows to do that. I'm not saying the innovation pathway is going to go away. It's going to be there, and we're seeing plenty of it in urology, but the payers are really trying to get a grip on this by introducing more controls on how they're going to pay for things.

So circling back to the LCD and LCA for Botox, one of the things we would recommend is that everyone take a look at what those documentation requirements are. When we're looking at overactive bladder, neurogenic bladder and incontinence, what Medicare is looking for with the NCDs relative to sacral neuromodulation and sphincters, and the administration of Botox, is a lot of precursor information that needs to be collected from the patient: what therapies have been tried, or what therapies were considered but dismissed because of contraindications. Do we have bladder diaries? Do we have all this up-front work that was actually collected from the patient, and the protocols or treatment attempts that have been made in the past that need to be done prior to that next step?

That led me to suggest that you really think about implementing a checklist, to boil it down to the easiest phrase I can think of. Essentially, make the information that is needed for the LCD or the NCD part of your treatment approach. If you spread it broadly enough across your practice so that all of your patients fill that information out, and you're documenting along the way that you've met all these requirements, and many of them overlap, then you have the option to treat patients the way you would like to treat them, because every one of them has that backup documentation that's now required as part of an LCD or an NCD.

Building the requirements into intake forms and clinic flow

[16:00] Scott: A couple of questions. Ray, maybe I'll ask you first. As a urologist, given what Mark just explained and his recommendations, when you're looking at how you document your procedures, what do you recommend? Do you go out and read that LCD? Do you read the LCA? Do you read the synopsis of it? How do you build that checklist?

Ray: While I was still in practice, I found it very helpful to have the patient fill out an intake form with specific questions related to the disease process they had going on. One, it gave me information to work with, but two, it also prepared the patient to answer my questions when I went to see them. So what I heard Mark say is that they need to expand their intake form on all of these things related to incontinence, urgency and frequency to include all the questions you need answered if you're going to treat them with Botox, in order to satisfy the LCD, et cetera.

Scott: Mark, is that accurate?

[17:00] Mark: Ray boiled it down to the old flow of how things worked, to borrow a urology piece, but it is accurate. Building those in is information gathering, whether it's intake you get from the patient on the patient portal or a form that needs to be populated by the clinician when the patient is in the office, in the form of a template in your EHR. Those are the things that need to be addressed early on and throughout the treatment process, so that you have all that information for every patient and you're not worried about it.

Now, it does need to fit into the clinic flow. Not every patient has incontinence right off the bat, or it takes some investigation. But once they get to the point where you're dealing with a disease state like incontinence or overactive bladder, where you're potentially looking at a treatment that falls under an NCD or an LCD, why not have that information in place? Why not start the patient working on a bladder diary? Those types of things need to be worked into the flow and the clinical pathway within each office. Can you make it clinically relevant and administratively easy? Those are the two things you want to deal with in a forethought, planning manner, and implement across the practice for everyone to meet those required steps, so that you're not, A, getting blocked by a WISeR program or a prepayment review, or B, paying things back because Medicare is stepping up the analysis of how they're paying for things.

And to make everybody's sphincter pucker just a little bit more, which I don't always like to do but feel I have to: Medicare is hiring more and more in the auditing phase. They're going to look at that. They're also leveraging AI more and more to look at medical records to see how things are being paid. And we know that UnitedHealthcare and some of these other payers are downcoding to look at more medical records. There are so many things out there pointing to the fact that record review is going to be a part of payment in a much broader sense, for takebacks, look-backs or prepayment, that we really need to plan for it and leverage the tools we have to build the medical records in a way that supports the care we know the patients need, before they necessarily need it.

Scott: Ray, do you have any questions?

[21:00] Ray: Mark just added to my comments. The second part is that we've always talked about documenting for clinical purposes, but you also need to document for reimbursement. We have clinical pathways, the scientific ones that come from our specialty, but now we also have clinical pathways to get paid. So you have to add both of them to your work process.

Mark: Financial clinical pathways.

Ray: That's right.

Scott: A new category.

Mark: Yeah.

The Botox LCD: which MACs and states are affected

[22:00] Scott: All right. I'm going to get some final thoughts here. I know we hit this at a very high level. But before we do, Mark, can you dive a little more into the Botox LCD, just to give the details of what it's saying, so we're a little more informed? We sent out an alert that had a summary of the Botox LCD and the implications for the practice, so we can walk through that as well. We'll post a link on the episode site. If you go to prsnetwork.com/279, you can get a link to the alert we sent out.

Mark: Very quickly, with Botox, the local coverage determination went into place for six of our contractors, the Medicare administrative contractors. That was Noridian, and you're going to have to help me with this: WPS, I believe Palmetto, and was it NGS or CGS? I always get those two mixed up.

[23:00] Scott: I'll pull it up in just a second. It was Palmetto, CGS Administrators, NGS, Noridian and WPS. That covered the states Alabama, Georgia, Tennessee, North Carolina, South Carolina, Virginia and West Virginia for Palmetto. For CGS, it was Kentucky and Ohio. For NGS, it was Illinois, Minnesota and Wisconsin, and Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont. For Noridian: California, Hawaii, Nevada, American Samoa, Guam and the Northern Mariana Islands, as well as Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming. And then for WPS, it was Indiana and Michigan, as well as Iowa, Kansas, Missouri and Nebraska.

Mark: So most of the states. I think it's 35 states.

Scott: Yep.

Mark: I don't know that we want to list all of that. That's a lot to absorb on a podcast, isn't it?

Scott: Maybe. We'll see.

Botox coverage requirements for OAB, neurogenic bladder and IC

[25:00] Mark: So we'll put that list up. The LCD went into effect for Noridian, WPS, CGS, NGS and Palmetto as our contractors, and it covers about 35 states. We'll put that information up in Scott's link. It covers Botox across a lot of different specialties, not just urology: ophthalmology, orthopedics. So it's a fairly long LCD, but boiling it down to urology, we ended up with three main areas that it addressed.

One was overactive bladder, or urge urinary incontinence, coverage. There are specific documentation requirements there: an objective scale for overactive bladder, failed 12 weeks of conservative therapy, and failed or contraindicated anticholinergics, with a specific dosage of 100 units per session. We know a lot of practices look at higher dosing as patients go through the process, but know that Medicare has it at 100 units per session. And the documentation of the anticholinergic failure, the 12 weeks of therapy, the objective scale and a UA all need to be done prior to each visit. They have to be updated and documented before each session.

They also specifically noted that OAB in and of itself is not really a diagnosis. So they put some coverage restrictions on the diagnosis codes, which include urge incontinence, incontinence without sensory awareness, post-void dribbling, nocturnal enuresis, continuous leakage, mixed incontinence, overflow incontinence, coital incontinence, postural urinary incontinence, and other specified urinary incontinence, but not OAB. OAB by itself is not a covered diagnosis. You have to have one of those others.

Then they also have neurogenic detrusor overactivity, or neurogenic bladder, for which you can administer a dose of 200 units. This is really following the FDA labeling for Botox. That is covered for reflex neuropathic bladder, not otherwise classified; flaccid neuropathic bladder, not otherwise classified; other neuromuscular dysfunction of the bladder; and neuromuscular dysfunction of the bladder, unspecified.

The last of the three is interstitial cystitis, or bladder pain syndrome, again allowing 200 units per dose, with specific diagnoses of interstitial cystitis without hematuria, interstitial cystitis with hematuria, and other symptoms and signs involving the genitourinary system as covered diagnoses, again pointing back to the overall interstitial cystitis and bladder pain syndrome.

So you want to make sure you understand all of the documentation requirements, and you do want to go take a look at the page. As I mentioned, building those protocols into your workflow would be very intelligent. And then, of course, understand the back-end coding requirement of which diagnoses are covered, which are not, and how many units are covered for each of those treatment areas.

Final thoughts and closing

[29:00] Scott: All right. Let's go ahead and wind this episode up. I'm going to ask for some final thoughts. Ray, final thoughts, or did you have any questions? I didn't ask if you had any questions on the Botox.

Ray: No, I don't have any questions. It's just a reminder that this system is not impossible to understand, but it is detailed.

Scott: That is for sure. All right, Mark, final thoughts.

[30:00] Mark: I think I can sum up my final thoughts pretty succinctly: leverage your tools and leverage your workflows. That's what really needs to happen. It's maybe unfortunate that this change is occurring, and maybe not, as you look at care overall and where you really would like things to go. But we are moving more and more toward clinical pathways and treatment protocols that are going to be more similar than not as we move forward. So make sure you are leveraging your tools to collect the right data and have it available to navigate this reimbursement environment, so that you can provide the care the patients need.

It's just part of the game. I like to say that it's different, and you should be able to practice medicine as an art, but it's becoming more and more menu-driven, for lack of a better term. At least there are choices on the menu. But it is one of those where you're going to have to play that game. We've been encouraging you to do that for a while, but every step we see is one step further down that pathway.

[31:00] Scott: Yes, indeed. 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. That's all we have for today. Take us out, Ray.

Ray: Happy coding.

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