Key takeaways from this episode

• Repeated appeals of Testopel denials from Anthem, UnitedHealthcare and Blue Cross Blue Shield are unlikely to succeed. Payers increasingly classify testosterone therapy as patient comfort rather than treatment of a disease state, and pellet dosing often exceeds what LCDs and LCAs allow, which drives the "not medically necessary" and "no authorization" denials.
• Treat the patient as the primary payer for Testopel going forward. Use an ABN for Medicare patients, and for commercial patients check whether the contract permits billing the patient for non-covered or unauthorized services before providing them.
• Existing unpaid commercial Testopel claims usually cannot be shifted to the patient after the fact. Most contracts restrict patient billing after a medical-necessity or authorization denial; the remaining lever is asking the patient to complain to the plan, and manufacturer or compounding-pharmacy relief has been rare.
• Get prior authorization from the Medicare secondary payer for high-cost drugs such as the new bladder cancer agents. A growing number of secondaries now require their own authorization even when Medicare primary does not, and the margin on these drugs will not absorb a partial miss.
• Do not bill 96160 for urology symptom questionnaires such as the AUA-SI/IPSS, SHIM or OABSS. Medicare and CPT Assistant treat 96160 as a health risk assessment instrument (for example, screening for mental disorders), while these tools are diagnostic symptom scores that belong in the subjective portion of the E/M note.
• A 96160 claim will probably pay, but it is a takeback risk for about $3.01. The code carries practice expense only, with no physician work; interpreting and discussing the scale is already included in the E/M service.
• The new Botox LCD adopted by six MACs requires a standardized assessment instrument to categorize incontinence. That documentation requirement is separate from, and does not justify, billing 96160.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 280, recorded March 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Unpaid Testopel claims: why payers deny them

[00:00] Scott Painter: On this episode: unpaid Testopel claims. Also, secondary payer payments are no longer automatic. And finally, we'll talk about health risk assessments. Do they apply to urology? Stay tuned. Welcome to episode 280 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 dive right in. We want to talk about a question we got in about unpaid Testopel claims. Then, as I mentioned in the intro, we also want to talk about secondary payers and what impact they're having on claims being paid. And finally, we had a question that had to do with health risk assessment tools, and specifically tools in urology. Are they health risk assessment tools? Do they apply?

This was a question that came in from Jennifer, and Jennifer says: I have about 18 unpaid claims for Testopel with Anthem, UnitedHealthcare or Blue Cross Blue Shield, all denied for not medically necessary or no authorization, when all attempts to get authorization failed because during the authorization process we were told it was not attainable. She goes on to say that when she attended our seminar, it was mentioned that this is an ongoing issue across practices, and was wondering if we have found a way to get these claims paid. She says she's appealed most of them multiple times and is not getting anywhere, and is just wondering what our recommendation is. All right, Mark, what's going on here? Are we seeing this, and how do we deal with it?

Mark Painter: Yeah, there are a lot of denials around Testopel, and there are a number of different responses that we have received relative to Testopel. One of the base-level issues we've got in dealing with testosterone in general, and Testopel specifically, is some of the dosing recommendations from the FDA, as well as the fact that many folks who are on Testopel are on it for reasons that are considered more patient comfort than truly treatment for a problem. And of course the other part of this is that a lot of the marketing for all the Testopel and testosterone treatments out in the marketplace, for women and for men, has focused around generally better health. But in the end, it's not treatment of a disease state as much as an aging issue, or something related to hormones, that is better categorized, maybe, by the insurance companies as, again, that patient comfort side.

So even though we've got specific diagnoses around this, and we have ways to test for testosterone levels and targets for what normal testosterone levels are, Medicare and many of the commercial payers, and this is where the focus is, on Anthem, UHC and Blue Shield, have really started shifting their benefit policies and classification of testosterone treatment to patient comfort, rather than focusing it on a disease state that truly needs to be treated for the patient's health. It's not about their feel-good or mental capacities as much. In short, it's not life-threatening, and it's not part of that intervention focus that much of the insurance is built around. So that's the base-level problem. Now, Testopel in particular is an issue because, as a slow-release testosterone, many of the patients require, in the opinion of physicians, more testosterone than what is allowed under LCAs and LCDs.

So unfortunately I don't have a great answer, and we have not found a great answer overall to getting a lot of these claims paid, especially those that are above the limit, if you will, of testosterone pellets. This is something where, if you are going to continue, you want to look at what your contracts allow for patient payments. We do have ABNs and that pathway for Medicare, but that is one of those areas where you probably need to consider the patient as the primary payer for those services and for those drugs, based on the way the classification of treatment and disease state is under those payers. That's why you're seeing not medically necessary as a common denial, or no authorization, which is driven by the fact that maybe the drugs aren't set up within their authorization system, or the testosterone is not set up within the authorization system because it is, again, not medically necessary for most disease states. That's where those things are coming from, and probably why the multiple appeals have not resulted in payment. Because, as we all know, unfortunately, the patient comfort side of the equation is not really the insurance company's concern. Their focus is on intervention for catastrophic issues.

Can you bill the patient, and can the manufacturer help?

[07:00] Scott: All right, so let's say those unpaid claims are not going to get paid by the payer. Obviously, for Medicare you have to have an ABN to go charge the patient. But for commercial, is it the same, or how do they handle that? Can they now go bill the patient even though they didn't get anything signed by the patient? Is there any way to recoup any of those missed payments?

[08:00] Mark: That depends on your contracts with Anthem, UHC or Blue Shield. I'm assuming, based on the question, that there is a contract in place for each of these commercial payers, and in that case it is about the contract. There are some contracts that do allow you to provide services to patients that are non-covered, but with denials of medical necessity or no authorization, they are often very restrictive on whether or not you can go back and capture that from the patient. So, as much as I'd like to say you can just flop it over to the patient, that's not easy to do. Now, the one place you could potentially leverage the patient, if you are not allowed to bill the patient, is basically to let the patient know that they may be able to help get these services covered, because the patient complaining that they needed these may make the insurance company change their mind, although in these cases it's difficult. But that's the other potential pathway you have if you're not allowed to bill the patient.

Scott: Final question from me on this: what about the manufacturer? Are there any opportunities to go back to the manufacturer when this happens and see if you can negotiate anything?

Mark: It's always worth the effort. I will say that Testopel, even though that is a brand name, we use it fairly generically, like Kleenex, and a lot of those implantable testosterone pellets are provided by compounding pharmacies that may or may not have strong backing or strong qualifications for rebates or anything along those lines. It's certainly something you want to make sure you are paying attention to, and run that by them and maybe get some costs down up front. But I have not seen a lot of people, depending on who their source is, getting a lot of relief by going back to the manufacturers.

Secondary payers now requiring prior authorization

Scott: All right. Let's move on to the next topic. This came up in one of our UPTP discussions, which is our Urology Pharma and Tech Pioneer group. We were talking about secondary payers causing problems with some of these large-ticket items, like the new bladder cancer drugs. Mark, do you want to shape what's going on and what's happening with that, and why we wanted to talk about it?

Mark: Yeah. The issue has arisen with some of these higher-cost drugs, and of course everybody's watching those very closely because it's a significant out of pocket, and although there's a margin in there, it's not large enough to cover a miss or even a partial miss. That's where we are in the marketplace today with the costs that are there. What we're finding now is that the secondary payers from Medicare are requiring prior authorizations to cover their secondary portion of those bills related to those higher-cost drugs. So we now have a number of groups who are making sure they get authorization from the secondary payer. It's not every secondary payer, but it is a growing number of secondary payers that are looking for those prior authorizations, even though they may not be required by Medicare as primary. So you want to look at obtaining those, pay attention to where denials are coming from, and definitely step that up. Ultimately, with these larger drugs, where it's not an option to have a fail, maybe you throw some overkill onto this one. I know it's an additional burden on everybody's prior auth departments, but it seems to be the name of the game right now.

[13:00] Scott: Ray, any thoughts on the secondary payer marketplace and how to deal with it?

Dr. Ray Painter: No, I was not aware that the secondary payer could do that. My contract with my secondary payer says if Medicare pays, they're obligated to pay their percent.

Mark: Keep that one.

Ray: I am. It's costing me dearly, but I'm keeping it.

Can 96160 be billed for urology questionnaires?

[14:00] Scott: All right. Any other comments on the secondary payer issue? Okay, let's move on to the final topic we wanted to cover. We saw it on the Thriving Urology Practice Facebook group, and it was really a discussion on code 96160. The description of that is: administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument. The ask on the page was basically: It was brought to my attention from other urologists that this code could be billed with administration of psychometrically validated standardized questionnaires in urology clinics, such as the AUA-SI, the SHIM, the OABSS, et cetera. They commonly bill this code with E/M services and are getting paid. I've never heard of this before, and hence why I am asking about it. Has anyone utilized this code for questionnaire administration? From my initial review using OpenEvidence and ChatGPT, it seems that this code was intended to be utilized in behavioral health settings, but the language does not specifically exclude a validated urologic instrument. Any thoughts will be welcome. All right, Mark, that was a question from Jonathan. What do you think on that? What's your take?

Mark: Well, going through the Federal Register, there has been some discussion since this code was activated in Medicare in 2017. There were some discussions in 2023 in the Federal Register, and there were further discussions in 2024. The 2024 discussion offered some clarification, but not as much on the specifics as we would have liked. The general focus of Medicare's read on this code, and I think the CPT Assistant also has some information that Scott's going to read in a minute, is that both of those focus on these tools and this code being a health risk assessment test. When I consider the utilization of the standardized tests in urology, I do not consider those really focused on health risk assessment. These are more symptom analysis or diagnostic tools used by the urologist to categorize the disease state and figure out what the next step should be. Therefore, I would put these more typically into the subjective part of the E/M code. In the end, I don't see that if this code were billed it would necessarily get denied, or that there would be a request for a document review. But what I do see is that if they were ever reviewed, everything based on the risk assessment would be used against you in this particular code set, given what and how the IPSS and the OABSS would typically be utilized within a urology practice setting.

Scott: Ray, comments on that?

Ray: Mark, if I hear you correctly, we usually look at a code and try to figure out exactly what the requirements are and whether what we're doing fits the requirements or not. But we also look at the intent. What I hear you say is this is not really established for the intent of what a urologist would be using it for, and therefore you probably are running a little bit of risk in charging it, but you might get paid.

Mark: Yeah, you probably would get paid. But there is a risk here that it is not following the intent of the code. Scott, go ahead with the CPT.

What CPT Assistant and Medicare say about 96160

Scott: In the CPT Assistant, it says codes 96160 and 96161 will allow reporting of a patient risk assessment instrument administered to either the patient or the caregiver/parent in order to assess the risk of conditions such as mental disorders, when performed in conjunction with an E/M visit. It also says it's important to note that codes 96160 and 96161 do not include physician work and are related only to practice expense, including clinical staff work, supplies and equipment expenses. Services provided by the physician or qualified healthcare professional are included in the E/M code, which may be reported for the patient encounter. The separately reported E/M service includes interpreting the rating scale, discussing the results with the patient and/or caregiver, documenting the patient/caregiver discussion in the patient's medical record, and providing any referrals to the patient's or caregiver's primary care provider or mental health provider. So that's some of the guidance that is in CPT Assistant.

[22:00] Mark: Yeah. And layering on top of that, Medicare's focus on this as a health risk assessment is really where the focus of that tool and reporting this code should be. If in fact the documentation supported that those tools were used to assess the health risk to the patient, not the diagnosis of the patient, that's really where that documentation would lie. And it's hard. I can't say that any of those tools couldn't be used for health risk assessment. But I can tell you, after reading multiple charts, that is not the way the documentation reads for the majority of charts that I've read. That's where my caution comes in.

[23:00] Scott: Yeah. So if you bill it, you'll probably get paid. However, it's probably not the right code and probably not the right approach, and maybe subject to takebacks in the future.

Mark: And it's been interesting. The timing of this question is good in that we also had all of our discussions around the new LCD that the six MACs have adopted for Botox, which now requires an assessment instrument to categorize the patient's incontinence in order to justify the administration of Botox. So the timing was such that all this stuff comes up at about the same time. Probably folks are out there googling assessment tools and things that could be used, and that sends you down a rabbit hole with some interesting ideas and some creative ways to maybe look at a little bit of extra money, since, of course, they're not giving you raises as you move forward in treating Medicare patients or any of the other patients that are out there. So I completely understand why the digging is there and why you want to look at this. But I do think you want to be careful in making sure that your documentation supports the intention of this code, which really is administering a tool to assess the risk of the disease state for that patient as it relates to their overall health.

Scott: And the payment for that is $3.01. Just for your information, that's a national payment. All right, Ray, any other comments?

Ray: Nope.

Sponsors and closing thoughts

[25:00] Scott: Okay, let's wrap this episode up here. 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/prs for specials for our listening audience. Also, I want to remind you that the PRS Urology Coding and Reimbursement Hub is up and we're updating it consistently. You can go to prsnetwork.com/urologyhub and get all sorts of tools and information on urology coding, as well as products in the urology marketplace. And we do have a lot of PRS CodeMatrix guides out there that you can download. They're free of charge, so we encourage you to go check those out. All right, let's get some final thoughts and wind this episode up. Mark, final thoughts?

[26:00] Mark: So I guess the three themes for today. One, around Testopel: really understanding patient insurance and the focus of what insurance pays for is a constant battle, and it is one of those that you're not only figuring out for yourself, but figuring out for the patient, because they typically don't understand what they've actually purchased. They're looking at their wallet and what this is going to cost them, and of course the $24,000 or so that they pay per year for healthcare is too much in their opinion, so you're battling that as well. But they need to understand that in the end there are costs to providing that healthcare, and those costs are real, and there are costs that have to be passed on from you as the practice to them. So it's an education piece on your own, but it's an education piece as well for the patient. Understanding where you are and what you can do is important, and communicating that to the patient, and how it affects them, is equally important.

Then when we look at the last issue, relative to the patient risk assessment, that one falls in the category of "can I get paid" versus "should I get paid." Those things are small enough, ticky-tack, that they might fly under the radar forever. But again, the compliance that you're trying to look for on a day-to-day basis, and what you're trying to do, is not about bilking the system. It is about making sure that you understand the system to get paid accurately for what you do. So those are the two bigger ones that we covered, and I forgot the middle one.

Scott: Secondary payer.

Mark: Oh, and the secondary payer side of the equation. So much of what we do relies on getting paid by every responsible party. That is part of the payment process. The primary payer typically is paying 80 percent of what you are paid, or in some cases 70 percent, in some cases 60, depending on what the patient actually owes in their contract. Then you add on top of that the deductible, which is again back to the patient. So as you go through the process of figuring out insurance, it is important to make sure you cover all your bases, and your secondary payers are now requiring those prior authorizations more commonly. Don't leave any stone unturned up front. I know it's extra work, but when you look at the costs of not getting paid for that, it's worth the investment.

Scott: Ray, final thoughts?

Ray: Nothing to add.

Scott: All right, very good. Let's wind this episode up here. Thank you all for listening. That's all we have for today. Take us out, Ray.

Ray: Happy coding.

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