Key takeaways from this episode

• Start every in-office procedure decision with the coding status. Determine whether the service has a CPT Category I code, a Category III code or requires an unlisted code, what payers are actually paying, and whether any LCAs or LCDs restrict billing, then communicate that to both the clinical and administrative teams.
• Optilume has a Category I code and a national payment of roughly $2,600 to $2,700, but the margin on the disposable is slim. Add the cost of the required dilation or DVIU, ancillary disposables, instruments and anesthesia, and check the GPCI for your locality, because a Medicare case can be upside down in some regions.
• Run the financials with cannibalization and time included. New technology usually replaces a treatment you already do, and the value of a procedure that keeps you in the office rather than driving to the ASC or hospital belongs in the calculation.
• Vet three categories before bringing a procedure in: clinical, financial and operational. Clinically that means patient selection, for Optilume short bulbar strictures rather than long anterior strictures; operationally it means committed staff and a rehearsed workflow before the first case.
• In-office anesthesia works when state rules allow it and you protect the anesthesiologist's time. Anesthesia is paid mostly on induction, so rehearse the whole case, minimize room turnover, and let an in-network anesthesiologist bill the payers directly, or contract or employ a CRNA if you can find one.
• If you cannot get anesthesia, use nitrous oxide or oral sedation. Dr. Lin recommends the Pro-Nox or Nitronox Plus platforms, with a preference for Nitronox Plus.
• An OBL or OBS bills as place of service 11 and gets no extra Medicare facility payment. Some commercial payers have negotiated a separate facility fee on a contract-by-contract basis, and the build-out still requires state approvals and equipment such as crash carts.
• Fill the sedation room with other procedures to make the investment pay. UroLift, Rezum, transperineal biopsy, fusion-guided biopsy and PAE (which pays better in the office than the ASC) can all share the same room, anesthesia and staff.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 285, recorded April 2026, with Scott Painter and Mark Painter of PRS Network, and guest Dr. John Lin, solo urologist in Gilbert, Arizona and founder of the Thriving Urology Practice Facebook Group.

The question: is Optilume worth doing in the office?

[00:00] Scott Painter: On this episode, is it worth it to do more complex procedures in the office? Stay tuned. Welcome to episode 285 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, and we welcome back special guest Dr. John Lin. If you're not familiar with Dr. Lin, he's a solo practitioner in Gilbert, Arizona and the founder of the Thriving Urology Practice Facebook Group. Welcome back, John. Thank you for joining us again, and thank you for bringing us another hot topic to discuss.

[00:37] Dr. John Lin: It's my pleasure. It's always fun, and there's no shortage of questions from the membership in the Thriving Urology Practice Facebook Group. For those of you who are not members, you're missing out on a great free resource. Often some of the members tell me it's the only reason they're on Facebook.

[00:57] Scott: Awesome. What a great resource. Thank you for putting that together; we really appreciate the community that's involved with it. Let's get started. John, I'll toss it to you to read the question that sparked this discussion.

[01:16] John: Right. Because of my notoriety in coding, billing and practice management, I get direct messages, and I field questions from the Facebook group. This one goes something like this: "Hello, sage of billing. Is there any benefit to attempting Optilume for urethral stricture disease treatment in our office setting, where we have anesthesia come for IV sedation when performing minor procedures?" So, a seemingly simple question, but with so many implications. Mark, what do you think?

[01:52] Mark Painter: I'll start out with the standard, general answer of: it depends, on how you want to measure things.

[02:01] John: It's so true, though.

Building the business plan: coding, documentation, finances and cannibalization

[02:02] Mark: Unfortunately, it is very true, and it's not a simple calculation. As we address in our Urology Advanced Coding and Reimbursement Seminar, we take a segment of time during the meetings to go over new technology and what's coming out the door, and we've had a lot in urology recently, and we're not done. We talk about the coding, we give the vendors time to talk about the clinical side, and of course in our audience there's usually someone who's been there, done that, and played with the procedure. But one of the things we run the approach on with all of this is that adding a line of business, whether it's telehealth or a brand new technology, requires a plan, and coordination of that plan across your entire team.

So it does start, at least in this discussion, with coding. Where is it in the coding process? Do we have a CPT Category I code, a CPT Category III code, or do we have to use an unlisted code? What are we hearing in the marketplace as to what's getting paid? Do we have LCAs or LCDs that are going to affect how we can bill it? We need to understand that end game as a starting point, and that piece needs to be communicated to both the clinical side and the administrative side. So we need to build that communication within the office. The second step, based on what we find there, is to take the time to get our clinical team so that their documentation addresses all aspects of the code, or lack thereof, and the procedure itself with a really detailed description. We need all of those things in place. That's the foundational business piece.

Then comes the finance time. What's it going to take as an investment up front? How many procedures are we going to need to do to make it from a capital side, if we know what the reimbursement is? We've got to run those finances down across the board. Sometimes the finances come up clearly upside down, and at that point you're pretty much done until something changes in the marketplace. If the financial picture is solid and we know we're going to make some revenue on this, then, and the piece I skipped over and should not have is clinically, does this work, do your patients want it, and do you want to be involved with it? That is the first question you really need to ask, so I'm going to assume that one was done. Once you find out the financial picture, if it's really good, now it's time to build the protocols, procedures and office flow, get the communication in, and see how you're going to advertise.

I will tell you the one thing I think a lot of people miss when they run through financials looking forward is cannibalization. Most of these new technologies are going to change the treatment from something you have already been doing. So take that into account as you move through this process.

Then there's the last piece. If the money's not obvious in the full calculation of the build-out, but we're not going to lose money on this, the other thing everyone should look at is time and convenience. We've had this discussion with a lot of folks: we've got a shortage of urologists, and we've got a growing patient population in need. What can you do to make your day flow in a manner that allows you to treat as many patients as possible, appropriately? That time calculation, the value of time, needs to be taken into account as you look at each of these things.

I know the question for Optilume may have centered around cost. We know we have a Category I code. We know we have a payment set nationally of about $2,600, almost $2,700. We know what our costs are going to be. As we look at conscious sedation and whether we can bring that into the office, that's going to be an additional cost and additional revenue if you bring CRNAs in, or you have a contract that allows you to bill for conscious sedation. That's an additional break-even or revenue stream as you go through this. But it's tight. When we look at cost versus overall reimbursement on the disposable, you've got a fairly slim margin. Now you put in the time calculation and say, I'm not necessarily losing money unless I take into account that this takes me a long time to do. All of those things need to be calculated in.

For those folks who don't have the ability to have conscious sedation in their office, the other piece I would add to the equation is: what else can I do under conscious sedation that fits into this model? UroLift, Rezum, transperineal biopsies, fusion-guided biopsies, those types of things, which many people are uncomfortable doing under local, although I know there are people who do. That may be another value you can add to the room to keep that room and the personnel up and running. Nothing is an island, and that includes the space. Time, cost, equipment, resources, space in the office, whether or not you can get a CRNA, all of those things have to be part of the business plan and the answer to whether Optilume is something I can do in my office.

John's three categories: clinical, financial, operational

[09:02] Scott: John, thoughts, comments?

[09:04] John: I like to think of it in three broad categories whenever I'm thinking about bringing something into the office, and coincidentally I'm doing over 10 IV sedation procedures in the office today, including some of the minimally invasive surgical treatments for BPH. When you have it organized, it is extremely efficient operationally, and it's great for the patient and the families who have to bring them here. Before I bring a new technology into the office, I'm thinking of three categories: one, clinical; number two, financial; and number three, operational. Within each topic you have numerous subtopics to tackle.

Clinically, patient selection is going to be key. For instance, with Optilume, make sure it's not a long anterior urethral stricture. You want to concentrate on the short bulbar urethral strictures, and you have to make sure there's durability. I think data are out there demonstrating durability in short bulbar urethral strictures that have been treated numerous times. So clinically you have to make sure it makes sense, and then pick the right patients.

Then financially, ugh, big topic. Does this procedure have a Category I CPT code? Is it still a C code? Then you have to think about the cost of the device, and not only the device: you're supposed to dilate or do a DVIU before you do Optilume, so what is the additional cost of all the ancillary devices? What about the other disposables you're not even thinking about? Do you have the right instruments, or do you have to go buy new instruments? Do you have the facilities to actually do this procedure? And what about anesthesia? Are you going to have to hire an anesthesiologist? In my case, the anesthesiologist is doing the billing on her own behalf, so I'm concentrating on doing the actual procedure and the disposables and the other costs for the procedure I'm doing today. Another thing to look at financially is that it varies by geography. It may make sense for me to buy the device from Laborie and still be financially feasible with a very slim margin, whereas in Georgia or somewhere else, you have to look at the geographic practice cost index. If you're talking about a Medicare patient, it may not make sense in those areas if the GPCI puts you upside down. So financially there are so many things to look at.

And then lastly, operationally: making sure you have the staff committed to doing it. And like Mark said, what about the opportunity costs? Doing the procedure in the office is much more efficient, because I can bounce from the procedure to seeing a new patient or a follow-up patient and then bounce back to the procedure room to do another IV sedation procedure. I'm not driving to the surgery center or the hospital and performing this very expensive hobby. I not-so-jokingly say that any time I step foot in the operating room, I'm doing an expensive hobby. I love doing it, and I do it because I enjoy it and because I'm good at it. So yes, it's fun for me, but you have to think in terms of: if you want to be maximally efficient when it comes to productivity, is it worth your while to put in the effort to bring this procedure into the office, transperineal biopsy, UroLift, Rezum, et cetera? So it's three things: clinical, financial and operational. You have to look at every single detail within each of those three categories to determine whether this makes sense. I know it's a simple question, "Hey, should I bring XYZ into the office?", but you have to be very holistic in looking at this one procedure.

[13:10] Mark: Yeah. And as you mentioned, it's geography specific. It's also practice specific. We've got lots of folks out there looking at leveraging their APPs to do biopsies and cystos and things like that. So look at all your personnel, resources, everything you have. It is a practice-by-practice decision. Space, personnel, equipment, all of that needs to be taken into account for your business plan.

Getting anesthesia into the office and keeping the anesthesiologist happy

[13:42] Scott: For those looking at bringing something in who don't currently have sedation in their office and are not contracted with a CRNA, what would you both recommend? How does the CRNA or conscious sedation play into the practice, and how would you go about bringing that in if you were looking at procedures?

[14:13] Mark: It's a tough market right now for anesthesia. Ambulatory surgical centers are having shortages. It's a tough market if you look at it broadly. So John, you probably had connections locally and were able to offer incentives or something that gave you access to somebody to provide those services. That's another one where it's A, where you are, and B, who you know, and then where you can get access. John, go ahead.

[14:52] John: Healthcare is very hyper-regional, and what Mark is saying is right: it's difficult to get access to an anesthesiologist because, just like for most of us, Medicare doesn't really pay that well, and for the anesthesiologists it's even worse. They get paid the most during that initial induction, and the longer the case runs, their margin goes way, way down. So you may be enjoying your long case, nephrectomy, prostatectomy, cystectomy, but the anesthesiologist is crying at the head of the table.

The reason I'm able to make it work in the office is, number one, I can do it based on the state guidelines. The state allows me to have an anesthesiologist in the office to perform IV sedation safely. Number two, I am able to run things very efficiently. I can't blame the anesthesiologist in the office, because they are working as quickly as I can maximize things operationally. That means my staff has to be on board. Before I even hit go on the very first procedure, we have rehearsed the entire operation from beginning to end. So when the anesthesiologist comes in, her time is extremely predictable. I'm not wasting her time. We are turning the room over, we know where the patient goes next, we have the discharge instructions, everything is set up. The room turnover is minimal, and it's all hands on deck when we're doing this. She's able to maximize her time with induction and not waste every minute downstream crying at the head of the table. I don't like people crying in general, so I try to be empathetic to not just the patient, but also the anesthesiologist, my staff, pretty much everyone involved.

[17:00] Scott: And how does the anesthesia reimbursement work with the patients and with your anesthesiologist?

[17:07] John: She is in network with the few payers that I take. She bills directly to the payers, so I don't even have to touch that.

[17:21] Scott: And Mark, is that the way it's working in most offices you're seeing?

[17:25] Mark: Different groups have different options and opportunities. They may have their CRNA contracted for time. Some folks are big enough that they can employ them. I've seen a mix of everything out there. And they are scarce, so hanging on to that anesthesia is big. If you've got dedicated services, that's one of the battles you constantly fight: somebody trying to pick that person off or give them an opportunity to do things elsewhere. Regardless of your arrangement, it's a constant, ongoing service line that you have to keep up one way or another, whether it's contracted, internal or employed.

[18:17] John: Yeah. Whenever I'm in a surgery center, everyone knows me. If they can characterize me with one word, it's efficiency, because I'm empathetic to the plight of the anesthesiologist, not so much to the hourly workers in the OR, but the anesthesiologist. Same thing in the office. First you have to understand how they're paid, and then you have to be empathetic in making sure she's treated well and remunerated appropriately. She doesn't go anywhere else. She only comes to my office, and the reason is that I'm respectful of her time. I'm not wasting her time, I'm turning the rooms over, it's like clockwork when we do these procedures in the office. If you can't, and Scott, you asked about the folks who can't have anesthesia or there's no availability, then you have to think about other forms of sedation, such as oral sedation. I highly advocate nitrous oxide, laughing gas. People throw the phrase "game changer" around all the time, but it's truly a game changer in the years I've been using nitrous oxide. There are two platforms I would recommend, Pro-Nox or Nitronox Plus, with a hat tip to Nitronox Plus. If I have to spend money on it, that's what I would recommend.

OBLs, OBSs and the site-neutral payment problem

[19:47] Scott: All right. Mark, when we were preparing for this episode, you had mentioned OBLs and OBSs. Do you want to touch on that?

[19:59] Mark: I think a lot of urology groups have gotten acquainted with OBLs because of PAE. That's the preferred vehicle for providing PAE. It's one of the few procedures that actually pays better in the office than in the ASC, and you do need that extra equipment, and you do need conscious sedation for a PAE. An OBS is similar, in that you're essentially building up the capabilities of that location within your office. I get a lot of questions about building those out, and the question is, can I get paid extra? The place of service for an OBL or an OBS is 11, so it is the office. Your office-based payment is the overall payment to an OBL or an OBS when it comes to Medicare. There may be some payers, and I've talked to groups that have negotiated a separate facility fee from some of their payers, so there may be options with some of your commercials to get a little extra money to provide services in your office. But that's on a contract-by-contract basis, and again, part of the geography of where you are and the competition, which is part of the geography. You have to take all those things into account. The other argument I would throw back in the mix is time, the efficiency and operational side. It's a balance on the equation.

The thing I've railed about for a long time is that the system we have with CPT codes is not built well for, and has sort of been shoehorned in to accommodate, what we can do in the office at this point in time. That was not part of the original equation when the RBRVS and the physician fee schedule were developed. So we're subject to all the conversion factor reductions and the practice expense issues. It really needs to be split out. We need to look at things site neutral and move things around, but I don't see that happening soon. I know lobbying efforts are there, but if we could change that, it would be a game changer for patients and for physicians. Given the highly functional legislative process that surrounds Medicare, we just haven't seen it happen.

[22:50] Scott: That's so true. And just for the alphabet soup, can you go through OBL and OBS and define those?

[23:00] Mark: Office-based lab, office-based surgical suite.

[23:05] Scott: Those are governed by state regulations.

[23:08] Mark: They are. In the end, certifications typically are not as stringent for office-based build-outs like that, as opposed to an ASC, which may need a CON. But there are still regulations and approvals you have to have; you have to have crash carts. There are certain equipment and services you need to add to those sites to qualify for any extra payment, or ultimately to provide the services you want to provide. That does require an investment in equipment and sometimes in the infrastructure to support everything.

[23:53] Scott: John, comments, questions?

[23:55] John: For further alphabet soup clarification, PAE is prostate artery embolization, and CON is certificate of need, which is sometimes necessary before you start an ambulatory surgery center, also known as an ASC. I'm very empathetic to the folks who are new to this coding and billing game. It's truly crazy, the number of acronyms we use, and sometimes for CMS it's an acronym within an acronym.

[24:25] Mark: I wonder, when people start showing up and I start running through all this stuff, are we going to have earbuds that can translate healthcare?

[24:35] John: AI-assisted translation?

[24:38] Mark: I like that. But thank you, guys. I always forget that it's hard to follow.

[24:41] John: Yeah. When we talk among ourselves, we can throw these things around and we understand the implicit meaning behind every contraction and acronym we use, but for the general audience, I'm super empathetic, because it is very confusing.

[24:59] Mark: Yeah, it is.

Sponsor, seminar and final thoughts

[24:59] Scott: 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. Also, registration for the Urology Advanced Coding and Reimbursement Seminar has opened. We would love to see you all in Las Vegas in December or in New Orleans in January. It's a great experience and a wonderful two days, and we love getting everybody together and having these discussions, not only amongst ourselves but with everybody there. It's truly a great experience. Okay, let's get some final thoughts. John, final thoughts for today?

[25:54] John: I think it was the famous hockey player Wayne Gretzky who said you miss a hundred percent of the shots you don't take. When it comes to these office-based procedures, definitely look into them. But make sure you have a good understanding, and don't just take the word of the sales rep. It's very important to look at resources such as the PRS Network Urology Hub to look at the technologies currently available and the financial, coding and billing aspects. Look into it. Just because there are hurdles, don't dismiss it outright. In urology, heck, we went through medical school and residency. Pretty much anything worthwhile that is meaningful, fruitful, financially beneficial and good for the patient takes work and effort. Bringing in an in-office procedure will take a lot of thinking, planning and operationalizing, but ultimately you will benefit your patient, and hopefully, with the right planning, you will financially reward yourself and your team.

[27:07] Scott: Great point. Mark, final thoughts?

[27:11] Mark: As John was mentioning, it's a full picture: operational, financial, clinical. As you get into each of these issues, you want to thoroughly vet each aspect of these services. It's exciting; we get all this new technology and we can do more for our patients. It's also, unfortunately, time consuming to plan, but failing to plan is planning to fail. It needs to be a fully baked process. It's not "this is great, let's fire it up tomorrow and we'll figure it out." That's a recipe for failure. Communication, getting everybody on board, all of that needs to be taken into account. The other piece I will say is to weigh each of them, the operational, clinical and financial, across everything you do. There is no island within a urology practice. It is a functional organism that needs to all work together. So look broader. Yes, there are going to be focus points when you start the implementation side, but take a look at the whole practice, not just the one thing.

[28:37] Scott: All right. Thank you all for listening today. That's all we have. John, take us out.

[28:45] John: Thank you so much for the privilege of your time. Please take care of yourself and each other. Lastly, happy coding.

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