On this episode, New Fertility Information for Kidney Stone, Scopes, and Cheats. Stay tuned.

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Welcome to episode 295 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, my co-host Mark Painter, Dr. Ray Painter. And had some new developments for kidney stone scopes and sheaths. Mark, do you want to bring us up to speed? What's going on there and what are they what's CMS doing?

All right. Well, we've been having a lot of discussion around C9761 over the past few months, actually. And then of course, we updated you that there was a change for July 1st with the for the definition of code C9761 essentially being amended now. And Scott, maybe we could look up what the new description is to handle really all scopes with suction capabilities with an APC or in an ASC or an HOPD with code C9761, and then the introduction of the new code for C0814 for treatment of stones using a suction sheath. And so if we can read both of those definitions, Scott, okay. We can get everybody on the same page.

Okay. So the C9761, the new description for Q3 2026 is cysto urethroscopy with ureteroscopy and or pyloscopy with lithotripsy and ureteral catheterization for steerable vacuum aspiration of the kidney collecting system, ureter, bladder, and urethra if necessary, with use of steerable ureteral catheter or suction integrated ureter scope. So that's the C9761. And the new code is the C8014. And that description is cystourethroscopy with ureteroscopy and or pyloscopy with lithotripsy, including use of a suction-enabled ureteral access sheath with irrigation, and then in parentheses, if performed. So those those are the two descriptions.

Okay, so essentially last time we talked to you, we passed on that in treating stones, we've got the physician coating and with lithotripsy in the kidney and ureter. We've got our five two three five three and our five two three five six. So cysto urethroscopy of the re ureteroscopy of the lithotripsy, the five, two, three, five, three, and then the same code, essentially five, two, three, five, six, or the same description, but with the insertion of a stent. So the coding for the physician is not changing moving forward. But the facility now has three different options of coding based on the equipment that's used to complete a lithipsy treatment using a scope. And those are the five, well, four different options. If no stent was used and you didn't use any suction capabilities, the five two three five sticks for treatment with a stent insertion and no suction, essentially. And then the C8014, which is of course the lithotripsy with the sheath, as Scott was talking about, the suction sheath, and the C9761 for lithotripsy with suction and a scope. And so each one of those options are gonna be the coding for the ASC or the HOPD, even though the physician's gonna stick with 52353 or 52356, depending on whether or not they used a SNET. So that's that I think is what we talked about. And hopefully everybody's fairly clear on which codes to select and when. What we didn't have when we talked about this before was the full reimbursement picture as it started on July 1st. So we thought we'd update you there. And then additionally, since we talked to you last about these codes, we've got the proposed rule for next year, which provides some interesting information. So we'll start with Q3 reimbursements. So one of the important parts of looking at reimbursement, how it's calculated, and what it means are the statuses that are assigned to each one of these codes in the HOPD and then correspondingly in the ambulatory surgical center. So everything is married together, if you will, under the outpatient prospective payment system rules that were created by Medicare. These are essentially group payments, and we've maybe talked about this a little bit before, but essentially what happens is the procedures that are performed in an outpatient hospital setting or in an ASC are grouped into specific categories. There's eight different categories in urology for all of the procedures that urologists do that are assigned to these grouped payment codes for the ASC and the HOPD under OPPS. And what Medicare does to determine how the ASC is paid relative to the hospital outpatient department is take a look at a percentage drop, essentially, in two different sides of the equation. One is the payment of the actual devices that are used, which basically in a marketplace kind of cost the same thing in the U.S. And then the second piece is the general overhead and the cost of staff, which is projected to be lower in an ASC versus an HOPD. So essentially ASC payment rates are somewhere around 40% as a starting point of what the AS or what the HOPD is, but that varies based on several different rules and groupings as they assign things into the OPPS system for ASCs. So we're gonna start off talking about the HOPD at this point in time. So when we look at the HOPD payments for Q3, so quarter three, that'd be July 1 through the end of September, right? That's three months because of all the calendar stuff that's out there. So right now, the HOPD gets a payment for C9761 of $9,671.50. So that's the HOPD rate. Now, just like the physician fee schedule, there are adjustments for different locations, although they're a little bit different as to how they refine those adjustments. Different hospitals will get paid different rates based on the adjustments for the geography and for some other and for a few other considerations. So we're just going to give you the national rates. The C8014, the 52356, and the 52353 payment to the hospital for Q3 are all the same and set at $5,477.93. And everything that's done on the same date is kind of rolled into that one code, if it's the highest paying. So they're going to pay just one of those. If you use a suction scope andor a disposable steerable scope and a sheath, that's only one is going to get paid in that setting. So when you bill for the C codes, the C9761, if you're using a disposable steerable scope and a sheath, you actually would not report more than one code. You'd just report the C9761 for the scope that has suction capabilities that was used because that is the highest APC that is assigned in the HOPD. So you would never report both, even though you may have used maybe a steerable scope with a sheath, with a suction sheath. You would only report one of those C codes. And the payment to the hospital would be based on that C9761. So the nine thousand six hundred and seventy-one dollars and fifty cents. And I'm sure it's just coincidence that kind of matches the C9761 almost. So that's kind of that's that jumping off point.

And do you want to bring up now about the device intensive, the other codes that you would include on the HOPD, or do you want to talk about that in a minute?

So no, we should do that because they are all or both the C eight zero one four and the C9761 involve devices that they are trying to track because of their cost relative to the overall payment, you would also report, or the hospital would also report the equipment that was used. So even though C1747, which is for the disposable scope, is now considered bundled, you would still report the C1747 if you were a hospital outpatient department billing for C9761 or C8014. If you're using a sheath for the treatment, you're gonna report the C1889. There's all these numbers, and I'm sorry for those of you who are driving. So the HOPD would report both of those additional codes if a device, either a sheath or a scope, or both, would be used, you're going to report those additional C codes, even though they're not getting paid. So a lot of times when you have when you are submitting the C1747 and the C1889, you would submit the invoice cost along with the claim. So CMS can continue to collect that data because they have a device intensive modifier as well as the J1. So that's a piece of that on the consideration that you want to talk to your hospital about, because there are offsets and calculations that happen in the future based on the data that they collect. Now, when we move to the ASC, and that's the main reason I'm bringing this in, because I imagine the majority of you are not billing as an age, excuse me, you're not actually coding and billing for a hospital outpatient department. But if you're talking to the hospital outpatient department, you'll want to talk to them about that. But it actually has more of an impact when we go to the payment rates that are set for the ambulatory surgical center or the ASC. So when we look at the ASC, the payments for Q3 for the 52353 and the 52356 are the same. They're paid at $2,729.66 at the national level. C8014 is billed, is set the reimbursement set at $3,452. So unlike the hospital, which gets the same payment rate for all three of those codes, the ASC actually gets paid an additional $722.34 for the sheath that is now part of C8014. The payment for C9761, because it's actually assigned to a higher APC, which we saw in the higher payment in the hospital outpatient department, is going to be $6,612.45. So that's all based on the device inclusions. And we see that in the status indicators for those particular codes. So both C8014 and C9716 are assigned a J8 or a device intensive procedure. Now, because all of these costs are calculated under the hospital outpatient department when it comes to devices, you do not, in an ASC setting, for the majority of for Medicare and for the majority of commercial payers need to submit the C1747 or the C1889 and the associated invoice. Because they're not collecting that data at the ASC level, they're collecting it at the HOPD level. So that's a little bit different. And then I'm going to give you the status indicators for 52353 and 52356 and explain a little bit about those because it's going to make a difference when we move to talking about next year. So those status indicators, the status indicator for 52353 is an A2, and that is because that code was in existence when we started using APCs, and they did some crosswalking to balance out some of the site of service differentials. So they're taking a look at both the physician fee schedule and the OPPS or the outpatient prospective payment schedule to come up with an adjusted weight. And that then is multiplied by the conversion factor for the ASC to come up with the payment price. And then 52356, because it's a newer code, is assigned a status of J2, also a site of service differential. And Medicare really kept those different, not because they're calculated much differently, but to really indicate that there were different points in time, those were added to the system. And that was the G2, not J2. Oh, sorry, G2, thank you. On all of that. And based on that hospital adjustment, essentially the actual APC that's assigned to 52353 and 52356 for the last couple of years has been 50% of the HOB HOPD rate. So that we just calculated those numbers. So it's slightly higher than the 40 that it happens elsewhere. Now, so that's kind of where we sit today in Q3 with all of those numbers. I'll stop there before we get into the proposed rule and what we're seeing for next year. Scott.

All right. So I have a just a quick question for you from a different perspective. So if you know a lot of these apply to the ASC, and and the information that you're providing is good information about the payment that the HOPD and the ASC receive. And this is important for urologists because a lot of the urologists out there may not have necessarily an interest in the ASC or the HOPD, but they do have the influence or can suggest or request scopes and sheaths. So when you're, you know, when we're looking at it all, this is important for urologists to understand when they're talking to the various facilities that they're performing these procedures in.

The codes are 52353 and 52356. Whether you use a sheath, a suction sheath or a catheter or a scope or any of those things, you're getting paid the same. So you're looking at it. Most physicians are looking at it from the standpoint of what's the best treatment for my patient? And that could include things like: is this going to be a shorter time period in the OR? Is it going to be a longer period in time in the OR? Am I going to get a cleaner kidney? What am I trying to do? Is my patient going to recover more quickly? All things that could make a difference on your QPP. So there may be a reimbursement impact somewhere down the road, but generally the focus is on care and what makes the most sense for that patient. So translating from the clinical side, which of course you always want that as the lead argument as you're going in, you want to be able to have to demonstrate to the facility that the financials make sense as well. And then, of course, for those of you that own ASCs, you're wearing both hats, looking at both the financial impact to the ASC as well as the impact to you and what you do procedurally. So it is important, I think, to understand those things as you're thinking about am I going to use equipment? Which equipment am I going to use? What equipment works best? And ultimately, can each patient follow the same set of protocols? Or are you going to have different patients that need different things? And what I'm seeing is stone size, the patient's health, like all of those things, the patient's anatomy for that matter, and whether or not they can accommodate a larger French scope, all of those things are going to make a difference on what type of equipment you're going to request. And if you've got kind of the arguments in from the financial side, demonstrating to your facilities, you know, what makes that all of these make sense, that's going to give you more options based on what's the patient's condition and what you think is the best tool to use for the job.

And you know, we've heard that some urologists are using, you know, not only the steerable suction scope, but also in you know, going with the sheath as well. So they're doing both disposable suction sheath as well as the scope with suction. And I mean, that's it, that's another interesting twist, you know. And obviously, if you do that, the facility only bills the C9761, even though the scope and the sheath were used. So it's interesting. And then that's a clinical decision, again, based on stone size and your patients and that. So if if that works better for you as a urologist, then that's a discussion. But just knowing that's how that's billed, you can't build a C9761 with the C8014. The facility can't bill that.

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Ray, did you have any questions or comments?

No, I you made the point clear. You do have to be involved because they have to buy your equipment.

All right. Okay, let's hear about next year.

What's proposed? So what's proposed for next year? So as a general proposal, Medicare has proposed a standard for them 2.4% increase in the HOPD and the ASC rate. So that's across the board that they're looking at that 2.4% adjustment. They're also proposing a number of other very significant changes in how 340B drugs are being used. They're putting more services available to be performed in the A in the ASC by year by continuing the three-year phase out of the inpatient only list. And they're adding more services to the covered procedure lists in the ASC. So the current CMS is really focusing on trying to drive care to other sites of service and to level out some of those sites of service, their site of service differentials. Now, I definitely don't agree with the way they're approaching a lot of these, because on the other side of the coin, they are making significant moves to try and save money in Medicare spending under the guise of protecting patients from Part B premium increases. But there's all sorts of activity that we're seeing around that big push to save more money in Medicare. And we'll leave a lot of that for another day. But there's a def they've definitely dialed it up to 11.5 for fraud, waste, and abuse, which we're all feeling the pinch on. But they're also for next year adjusting some of the scaling methodology that they're using for comparisons of HOPD rates to the ASC. So you'll see this reflected a little bit when we go through the numbers proposed for our four codes that we're talking about today for next year. So in the HOPD for 2027, they're proposing C9761 has a national rate of 10,796.79. So that's an increase from 2026 for today's rates. They're also proposing that C8014, 52356, and 52353 are placed into the same payment APC. That's going to go up to $6,292 and ten cents. So those are scaling up based on the general overall percentages. In the ASC, we found things to be very interesting. So the cost of device increases are flowing through in the proposed rule. So C9761, which is going to continue to be status J8, is going to be paid at $7,163.26. So that's going up significantly. And then the C8014 is going up to $3,663.78. They didn't propose any more changes in the coding structure. So all the coding is going to be the same next year, but we are getting an increase and not an insignificant bump in the cost for each one of those procedures going into 2027. What was interesting as we're going through all of this is that 52353 and 52356 for the ASC are actually going down by a couple of percentage points to 2,680. And that is where my comments about the status assigned in the ambulatory surgical center is very important, and has been affected by the scaling number that Medicare uses to crosswalk payments in the hospital outpatient department to the ASC. So we're it's not a huge drop overall, but it is a drop that they're proposing for the payment of 52353 and 52356 for 2027.

And and you know, from a urologist's perspective, there the payment, we haven't seen what the payment difference, if there is going to be anyone for 2027 yet. So we haven't seen that information come out. But this is strictly the facility payment that you're talking about.

It is, yes. So we're hoping that today or sometime next week we'll see the proposed rule for 2027's physician fee schedule. But we have not yet seen that. So we don't know exactly what's going to happen to those relative values or to the fee schedule. We do expect it to go down when we see that because we lost our 2.4 or our 2.5% one-year temporary bump to the conversion factor, and we're back to budget neutrality. So, but we'll see what happens next week with that.

Sounds good. So stay tuned on that one.

Ray, any comments, questions? Just to clarify, Mark, you didn't suggest in any way that the facility payment for a physician was going to be any different in the ambulatory surgery center or in the hospital setting, right?

Regardless of whether it's paid in if they perform the procedure in the ASC or in the outpatient hospital department, the physician gets paid the same amount, and that is true. And it's also the same, regardless of what equipment gets used, the only potential differentiator in payment would be the 22 modifier, because a particular case, regardless of equipment, took additional time and effort, and your documentation supported the use of the 22 modifier. So good question.

Yeah, but it's really interesting that as we discuss this, going back to it's very important for the facility, but it's also important for the urologist to have the discussion when it comes to the facility side, if they're making decisions for what you're what equipment you're using. So that all right. Well, that that was a long one and a lot of information that you threw at them. Let's go ahead and 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 forward slash PRS network for specials for our listening audience. All right. Let's get some quick final thoughts. Mark, what are your final thoughts?

Yeah, so all of these discussions that we've had in the past few weeks, you know, have I think brought to light a little bit more I don't know if it's clearly, but certainly more to the forefront that you know, we've got different parts of the system that affect how we treat patients and how all of this gets navigated through the this crazy system that we're in. And I will have to say that what was once crazy is even crazier now at this point in time, as we're seeing shifts in prior authorization, takebacks, audits, rack audits, UPICs, like everything is dialed up right now, as I mentioned before. And everybody is, I think, rightfully, a little bit more on edge in looking at the margins that are out there as the pressure is really increasing to provide more for less or the same amount. So in the end, it's less to do more. And we've talked about this before you know before in other cases that essentially physicians are seeing a one-third more patients and taking home about the same gross income over the past you know 20 years, that's which is crazy. And we're all feeling the pinch. And I say we, I mean, from the administrative side, the coding side, the physician side, it's it puts everybody a little bit more on edge. And certainly that's coming through sometimes, I think, in the way we deal with each other. So it's important to take a step back, look at all this stuff clinically. Yeah, you know, as Ray says routinely, it we may not be where we want to be, or we think we should be, but we are where we are. And so we're all trying to navigate this system as best we can. And so preparing and understanding where everybody's pressure points are when you're advocating for your patients, hopefully this helps a little bit, at least in one little area. But it's important to give those considerations to everyone and to really understand what you're talking about as you're advocating for the patient and for the treatment that you feel is best for that particular patient. And the other thing I'll put in place is with the increase in prior authorizations and everything related to that pre-procedure work. It's important, as we've seen a lot of prior authorization fails and write-offs, to give your staff the time that they need to execute all of the prior authorization requirements, dot your I's, cross your T's, double check your contracts. All of that has just become so much more important. And the team aspect of billing from not only the physician office, but now inclusive of the ASC and the HOPD from start to finish. And by start, I mean prior to seeing the patient, you're really gonna have to spend that time to get a hold of that or assign expertise within your practice so that at least somebody has the capability to make the arguments that you think should be made for your patients. So divide and conquer, assign and work together to make sure that you're providing the care you really want to provide to your patients. Ray, final thoughts.

All right. I'll just remind you that the urology advanced coding and reimbursement seminar registration is open. You can go to PRSnetwork.com, and right there on the homepage is a seminar information and registration button. Also, the PRS Coding and Reimbursement Hub is up and running, and all this information that we are talking about with these codes and the kidney stone scopes and the coding associated with it is going to be on the hub and will be reflected not only in the kidney stone page, but also on the products that are related to treatment of the kidney stone. So the scopes and the sheaths. And you'll be able to see the individual discussions on that. And you can go to prsnetwork.com forward slash urology hub for the information on different urology categories as well as products for treatment of those categories. All right, that's all we have for today. Thank you all for listening. Take us out, Ray.

Happy coding and doing.

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