Key takeaways from this episode

• CMS is no longer accepting the CPT per-organism interpretation for UTI PCR testing. Following NCCI guidance, Medicare now wants units to match the number of procedures, methodologies or kits run, not the number of organisms reported, so 87798 times thirteen and 87481 times five no longer hold up in non-MolDX states.
• When one kit or methodology returns results for several targets, report 87801 (amplified probe) or 87800 (direct probe) once for that group. Five results from one vial, for example three resistance markers and two organisms, is one unit of 87801; a practice might end up billing a few 87801s plus 87481 units depending on how its organisms are grouped.
• Audit your lab's test configuration before changing anything. Whether 87798 per organism is still defensible depends on whether individual probes and kits are used per organism, so go back to your lab partner and document how many kits and methodologies produce the results.
• Understand the money: 87798 and 87481 pay about $35.09 per unit, while 87801 pays about $70.20. Moving from thirteen units of 87798 to a handful of 87801 units is a large reduction in reimbursement.
• For Medicare-denied PCR claims, submit a reconsideration with corrected coding rather than an appeal, and consider correcting claims from the past twelve months. Practices in active RAC or UPIC audits should respond rather than ignore the audit, and PRS is seeking legal advice on whether to appeal and file a corrected claim or accept findings and re-bill.
• Private payers without a published PCR policy are a take-back risk. You can keep billing the current way, but unless your contract sets a specific PCR rate rather than deferring to Medicare guidelines, expect possible recoupments on high-volume testing.
• The 2027 proposed rule raises the non-facility RVUs for 51715 by 284 percent, to a national rate of about $1,332.36. One ml of bulking agent is now built into the practice expense; urodynamics technical components drop roughly five percent and 55711 facility payment decreases.
• Prostate biopsy codes 55707 and 55708 get modest increases, with a new fusion-guided add-on code and revised fusion initial biopsy codes. E/M and 76872 are essentially flat, and telehealth-specific codes dip slightly but do not affect Medicare telehealth billed with standard E/M codes.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 297, recorded July 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

CMS shifts UTI PCR coding from organisms to kits and methodologies

[00:00] Scott Painter: On this episode: new developments in UTI PCR reimbursement. Also, proposed RVU changes for 2027. Stay tuned. Welcome to episode 297 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. We've got a couple of things today, new information for you. First, we wanted to start by talking about PCR reimbursement. There's been an evolution there. Mark, what's going on?

[00:42] Mark Painter: We've been talking a little bit about PCR on the podcast, and I can tell you we've been looking through a lot of PCR tests. I know not everyone in the country is currently using PCR testing for UTIs as we wait for MolDX approval in many of the carriers, since the issuance of an LCD back in, I believe, 2021, and some of the updates that have come around through that. There have been some states, those with MACs that don't participate in MolDX, that have continued to pay for PCR testing using a combination of codes. One of the codes that gets used frequently is 87798, and it has an MUE, a Medically Unlikely Edit, of thirteen. A lot of practices were testing many more organisms than thirteen, but knowing where the MUE was, practices were using thirteen units of 87798. Then we have another code, the test for Candida species, the 87481, which is an amplified probe technique to test for Candida, and that has an MUE of five. Some people were using that at five, testing for multiple species, in some cases more than five different Candida species, but with the MUE cap, billing it at five.

We talked earlier in the year, I believe it was April, about the OIG report on laboratory testing, and how 87798 and 87481 were both targeted in the OIG report as having significantly increased in volume in 2025. So that was a target of the OIG. The payers immediately reacted by denying claims. There were some RAC audits kicked off for PCR testing with UTI, and we've been talking about the argument that could be made, and had been made over several years, based on CPT guidance. The CPT guidance for testing was focused on identifying each organism if you got separate results on each organism.

Now, CPT's interpretation of a second set of codes, the 87800 and the 87801, which are multi-organism tests, was really driven primarily by those circumstances where maybe you tested more than one organism but you got one result, positive or negative. You didn't actually get an individual organism back as positive or negative. So if you had multiple organisms in, let's say, a sexually transmitted infection panel, and you were just looking for yes you have it or no you don't, and that result tested multiple organisms, the 87800 or the 87801 was the right code under CPT guidance.

Well, NCCI has had a directive in its guidance for quite some time that actually runs counter to the CPT interpretation, and its focus is on the actual test performed. It basically says when multiple procedures, methodologies or kits are used to evaluate multiple infectious agents, then your reporting should be equal to the procedures, methodologies or kits used to perform the test. When we started looking a little deeper, not every PCR test for UTI is set up the same way.

Through this lens, which has now become the solidified argument from CMS, they are basically stating: we are no longer accepting the CPT definition. We are driving the reimbursement definition from Medicare. If it's a test for an individual organism, run with a kit that only tests for that organism, then you would bill that one code for that organism. If you're testing for multiple organisms, and you're getting results back for each of those organisms, but you're using one procedure, methodology or kit, then CMS is now guiding for the use of the 87800, for a direct probe, or the 87801, for the amplified probe.

As we've looked through all of this, we've seen different organizations that use different testing kits or methodologies and individual probes to test by organism, in which case billing the 87798 would be appropriate. It doesn't mean you're not going to get denials and audits, but you're going to have to prove it to Medicare, because so many other groups are testing for multiple organisms with grouped probes and detection. They're looking at how many different kits, methodologies or procedures are being run and asking for reporting of those grouped tests. Most groups are using the amplified probe, so the 87801. Say you tested for three different antibiotic resistance markers and two different organisms, so five different results, and that came out of one vial with a specific set of probes and test agents for those targets. Then 87801 would be appropriate for those five results. If it were seven, it would be 87801 for seven results. So each group is going to have to really understand how their testing is done. This is going to take a bit of analysis on the back end of how your tests are being run.

We are looking at further definition relative to methodologies or kits that we can use in some of these arguments. I don't think it's the procedural side of this, because essentially we're talking about the same sample being run at the same time on the same machine. But it is pretty clear that many of these tests use multiple different pools of testing to get to the end UTI results that go back to the urologist. So depending on how your test is ultimately designed, we're going to have to look at that to figure out what configuration would be billed. Even though we have some individual organisms that have their own CPT code, we won't be able to report that individual CPT code if the results are obtained in the same kit or methodology we're using to get the results for a second or third organism. We're going to have to move to the 87801 for Medicare testing.

We'll have to see what the private payers do. But this is a major change. I'd like to be able to give everybody the answer on how to bill for PCR test codes, but I can't at this point, because we don't know how your individual configurations are set up. This is something you're going to need to go back to your lab partners on, really take a look through it, and develop a very coherent argument as to why you're billing the way you're billing: I'm billing maybe three 87801s, and then maybe 87481 with a number of units, depending on how I've grouped my organisms and how I can order and test those organisms and their resistance.

MolDX states, Z codes, and what the codes pay

[10:55] Scott: When you mention MolDX versus non-MolDX, this is the guidance impacting the non-MolDX states in this way. What about the MolDX states?

[11:14] Mark: I think in the MolDX states we're still looking for that Z code operation. In those MolDX states it's fewer than five that constitute a panel. So if you're billing 87801 times three, could that now be considered a panel that would fall under the LCD that is currently published? That's something we can definitely consider, but it is a multi-organism test. Are they going to look at it as a panel or not? Are they looking at the units being done? Certainly I think we've seen 87801 as a code that may be used in a MolDX state. So that may open up some of the MolDX states, but I really don't feel I have enough information to say yes right now. I have enough information to say maybe.

[12:28] Scott: And have you seen any Z codes come out that have been paneled and paid, or are they still forming the Z codes?

[12:39] Mark: I haven't seen any Z codes. I know we've got a PLA code, which isn't necessarily a Z code. That comes from CPT for a UTI test panel, which you can pursue through CMS with a proprietary lab. So there are those options and opportunities for the use of a PLA. But we still have the Z code issue for the MolDX states, and I'm not yet aware of one. I know there were some applications in, but I haven't seen the results yet that an actual Z code has been authorized with MolDX for UTI.

[13:24] Scott: And we're talking payment for each one of these is $35.09, is that correct? So if you were getting paid thirteen 87798s, that's $35.09 times thirteen, versus what's coming out now, where I think the max we're looking at is four or five. That's a big change. I also want to point out that the 87798 was for each organism. That's the way the definition reads. That's why the guidance from NCCI, which talks about running one amplified probe with one kit that checks multiple organisms, is the 87801.

[14:28] Mark: And Scott, that one actually pays $70.20, not the $35.

[14:32] Scott: Which one?

[14:32] Mark: 87801.

[14:34] Scott: 87801 pays?

[14:37] Mark: $70.20.

[14:37] Scott: So the 87801. But the other ones are $35.09, the 87481 and the 87798.

How the denial letters have changed, and what to do with denied claims

[14:45] Mark: They are. And again, we were basing all of the information, and the way reporting should have been done, on the CPT definition. That CPT definition was valid. But obviously the interpretation of the NCCI rules that are published, and then actually last year clarified in some web posts on how to bill multi-organism infectious disease panels as a general guidance tool, came out on the MACs that are not MolDX. It really appears that Medicare across the MACs has been looking at the overall AI interpretation of these things, and the interpretation in the letters we've gotten back from CMS, in the form of denials, RACs and UPIC audits, has changed over the past few months. It used to be a focus primarily on medical necessity and running that number of tests on patients. Now it appears they've generally agreed that if you're selectively running these tests on patients who are symptomatic, have been on antibiotics, or otherwise need more than a culture and sensitivity and a UA to be treated based on their presentation, that was the medical necessity hurdle we needed to get over, and a lot of folks did.

It's certainly not something you can run in place of a UA. It's not something you would run blanket in place of a culture and sensitivity. There needs to be a reason to run this extra PCR test. That was the first argument we dealt with. As we saw this evolve, it has now coalesced around the NCCI argument.

So what we're recommending right now is, number one, take a look and figure out what your PCR test really is made up of: how many kits, how many methodologies. How many different organisms are being tested doesn't drive the coding anymore. It's based on the methodology or kit being used to get your results. Once you have that information, for those tests on the denial side of the process, where Medicare has denied them, what we're going to recommend is that instead of appealing those denials, you submit a reconsideration with the new appropriate coding. You'll want to have some backup information as to why you made those changes to your coding going forward. Then, to prevent RACs, UPICs and lookbacks, you do have the opportunity to go back and correct claims sent to Medicare within the last twelve months. That's the other thing we've got to consider.

If you're in a current RAC audit or a UPIC audit, that's an area where we're doing a bit more research, but certainly explaining why you billed what you billed, because you're now under an audit, and a reconsideration is something we've got to consider. But we also have to consider the appeal of that claim and how that balances out. We're getting some advice from legal as to whether you should go ahead and file the appeal, and then, because it's under appeal, submit a corrected claim, or whether you accept the findings and then go back and re-bill. Not responding to a RAC audit has been something that, over time, we've felt was not a good thing. It's tracked within the record. And given the proposed rule that could allow Medicare to go back to any point in time at which a proven Medicare violation occurred and kick you out of Medicare, this is something we don't want to see folks admit to. So that's the legal part of this that we're now trying to figure out the best advice on moving forward. Ray, any comments, questions?

Private payers and the risk of take-backs

[19:27] Dr. Ray Painter: One quick question, Mark. You mentioned private payers and needing to find out what they're doing. But if somebody has a private payer that hasn't posted how they handle this, do you recommend using the Medicare approach or the CPT approach?

[19:50] Mark: I can tell you we've had a significant amount of take-back activity in the private sector recently as well. Obviously AI has been leveraged in a lot of different ways. Without direction to change what you're doing, you can keep going the way you're going. The question is: do you have the contractual protection that would allow you to keep that money once you've received it? Let's say it's processed and paid at the standard rate. If you've got a contract that says PCR testing pays XYZ, you're in good shape, keep going. If it's left loosely on Medicare guidelines as the directive for the processing rules those entities use, then with Medicare going back, the potential exists that the private sector could go back and do those take-backs.

That's what I worry about with all of this: what are the take-backs? Getting paid is one thing, so you could probably still get paid using those current methodologies. Maybe the right answer is go ahead and keep going and save your money, because the take-backs may be coming, or maybe the private payer is going to publish a rule moving forward. It's a bit of a gamble. Given what we're seeing in the marketplace, it's definitely a gamble. We've always said that just because you got paid didn't mean you were right. Now it's more apparent than ever that getting paid for something does not mean you were right, and those take-backs are difficult to handle, and some of them are big. It happens with high-volume procedures, so if you're running high volumes, you definitely want to prepare for the fact that an adjustment could be coming down in the future.

Proposed 2027 RVU winners and losers

[22:02] Scott: Ugh. All right, let's move on to our next topic: the proposed RVU changes, winners and losers. What did you find in the analysis, Mark?

[22:18] Mark: Digging deep. A lot of times what I do from year to year is look at changes greater than five percent up or greater than five percent down, and we highlight those for you. We did this on just the RVUs, so when we add in the conversion factor, which right now is proposed to be negative, we'll probably adjust a few more codes that were on the edge of that five percent and add a few more into the mix when we do it based on fees. But we started with the RVU side, and in the end we had very few codes with RVU adjustments five percent up or five percent down. I'll do these numerically as we go through.

Number one was the 51715. That had a 284 percent increase in the RVUs. This is the in-office version, the non-facility rate, going up by 284 percent, almost 285 percent. The Medicare payment for that code, which includes one bulking agent vial, is $1,332.36 as the national rate, proposed using the current conversion factor. That was a big jump, and as we discussed last time, it's because they've rolled the bulking agent, or at least one ml of the bulking agent, into the cost of the non-facility practice expense. So that was one of our ups.

When we discussed the technical component changes, you can imagine the codes that were affected by the recalculation of the technical components. For urodynamics, the technical components look like their RVU drops are in the five percent range. The total components overall are more in the 3.8 to 4 percent range as far as reduction. So we'll definitely see some reductions in urodynamics reimbursement for next year, and when we put in the dollar value, we'll probably have a few of those in the five-percent-down range for most of the urodynamics codes.

Then in the prostate biopsy space, we mentioned we had some new codes and code changes. There were some corresponding increases close to five percent, so we'll put those as noteworthy, and obviously when we put in the conversion factor, those increases will not be over five percent. But we do have some changes in the prostate biopsy codes once again, and some verbiage changes. We'll alert you that we have some bumps in the 55707 and the 55708, which are your transrectal and transperineal regional biopsies, one with fusion and a targeted lesion, one without. We've got a new code for each additional biopsy, whether transrectal or transperineal, that's fusion-guided, which we'll go over with you. And we've got some changes to the fusion initial biopsy codes that we'll need to work with you on to get the appropriate use of that code. And a couple of codes were deleted. We'll come back to those specifics at a later date when we get the true CPT verbiage and guidance, so we can give you a better picture of what needs to be done next year for documentation and templating. But know that we did see some increases in the initial codes and some decreases for the each-additional-lesion target codes, and a big increase in the each-additional-lesion for the in-bore.

We also saw at least some changes in the radiology codes we use frequently. Not much of a change for most of what urologists do relative to diagnostic ultrasounds. The 76872, one of our most common, is really not changing very much. It's about the same across the board. And we didn't see any big bumps to any of the E/M codes. We did see some slight drops in the new codes for telehealth, not a lot to phone home about, but we certainly didn't see any bumps. Ultimately, those are not going to affect your Medicare reimbursement for telehealth provided under Medicare, which will continue to be reported using the standard E/M codes. So they're there, but not much of a change. We're okay with our E/M and our telehealth moving forward.

[28:13] Scott: Ray, do you have any questions or comments?

[28:17] Ray: No, nothing to add.

[28:21] Scott: So all in all, there's not a lot of huge movement in a lot of the urology codes, from what you mentioned, except for the bulking agent code. Other than that, there wasn't a lot of movement.

[28:38] Mark: That's correct. Not a lot of shifts overall. The one thing I forgot to mention is we did see a decrease in the facility payment for the 55711, the biopsy code. There was one other code I thought I saw, but I guess I hallucinated that one. So not a lot of big changes. We'll say a lot of little changes. And of course everything focuses on the conversion factor, which hopefully we can see turned around at the last minute by Congress, most likely in the lame-duck session if that's going to happen.

Sponsors, final thoughts, and upcoming events

[29:24] 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. Also, we want to thank UroGen, manufacturers of Zusduri and Jelmyto. If you want more information on Jelmyto or Zusduri, you can go to jelmyto.com or zusduri.com. Let's get some final thoughts. Mark, any final thoughts today?

[30:00] Mark: One is obviously the PCR side of this is going to be an ongoing saga for a little bit. Those of you who have been using PCR testing might want to prepare for those shifts, and do it very quickly. We can certainly work with you to see if there's any assistance we can provide in analyzing the best steps, so it would be worth contacting us to see if we can assist with those issues going forward. But it's definitely time to make a change, unfortunately. And the consideration of going back and fixing things in the past is also a strong one, to justify what you're doing, and picking dates based on what you can affect versus everything. That's one. The second thought is, yes, we'll keep digging through the RVU structure. Obviously not nearly as much activity as we had last year. It goes back to when you asked me what this proposed rule was.

[31:10] Scott: Yeah.

[31:10] Mark: I would say mediocre, with the exception of the modifier 25 proposal.

[31:15] Scott: All right, Ray, final thoughts?

[31:19] Ray: Well, I hope everybody appreciates the depth of understanding you have to have about the rules and regulations and what's going on with the payers. I'm just blown away by how things have gotten more complicated, and thanks, guys, for digging in and making it happen.

[31:41] Scott: You're welcome. We'll keep digging through it and seeing what we can bring out and highlight, because there are a lot of changes, a lot of movement going on, and it seems to be moving only faster. So we'll try to keep up and keep you all informed.

That's all we have for today. We want to remind you that registration is open for the Urology Advanced Coding and Reimbursement Seminar. You can go to prsnetwork.com, and right there on the homepage is a seminar registration button if you want to find out more about our seminars in Las Vegas in December and New Orleans in January. Also, at prsnetwork.com/urologyhub, we are adding more and more information about urology coding categories, as well as products used in urology, and how to get paid for those products and for the procedures and services provided in those different urology categories. That's a great resource. We have vetted that information. A lot of times AI isn't giving you the right information, but you can look it up on the hub and verify it.

Finally, I want to alert you that if you're listening to this before July 30th, 2026, we are having our monthly webinar at 1:00 p.m. Eastern Time. For those who attend live, you can get a free E/M pocket card and wall chart. Mark is going to go over what it takes to make sure you're capturing all the information you need when you're using all the new technology, the AI ambient listening scribes, et cetera. And we also have a special guest from ModMed to help with that as well. That's all we have for today. Thank you all for listening. Take us out, Ray.

[35:21] Ray: Happy coding and billing.

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