Urology Coding and Reimbursement Podcast
Urology Coding and Reimbursement Podcast
UCR 297: UTI PCR Coding Changes, Audit Risk, and the 2027 RVU Winners and Losers
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July 24, 2026
In this episode, Scott, Mark, and Dr. Ray Painter examine a major shift in Medicare’s approach to coding UTI PCR testing. The discussion explains why reimbursement may now depend on the number of testing kits, methodologies, or procedures used—not simply the number of organisms reported—and what practices should review with their laboratory partners. The team also addresses denials, RAC and UPIC audits, corrected claims, potential commercial payer takebacks, and the continuing uncertainty in MolDX states. They then review the proposed 2027 RVU changes affecting urology, including a significant increase for in-office bulking agent injections, potential reductions for urodynamics, and additional changes to prostate biopsy codes.
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On this episode, new development in UTI PCR reimbursement. Also, proposed RVU changes for 2027.
SPEAKER_01Stay tuned. Today's episode is brought to you by ModMed. Do your EHR and PM adapt to your style of practice? The ModMed EHR and PM do, with benefits like remembering preferences and automatically suggesting documentation and billing codes. Urologists voted ModMed the number one urology-specific EHR and PM solution available. Built by urologists with input from yours truly. Stop wasting 60 minutes and 200 for each of your open or no show slot. Go to modmed.com slash PRS Network, set up an appointment with the team at ModMed Urology, and shift your urology practice into high gear. Imagine a solution on a tablet or the web that works seamlessly with revenue cycle management, analytics, telehealth, payment processing, patient engagement tools, and much more. ModMed is transforming health care by placing doctors and patients at the center of care.
SPEAKER_02Welcome 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. And got a couple of things today, new information for you. First, we wanted to start by talking about PCR reimbursement. There's just been an evolution of that. And uh Mark, what's going on there?
SPEAKER_01All right. Well, we've been talking a little bit about PCR on the podcast, but I can tell you that we've been looking through a lot of PCR tests. And I know not everyone in the country is currently using PCR testings for UTIs as we wait for some of the Moldy X approval in many of the carriers since the issuance of an LCD back in, I believe it's 21, and some of the updates that are that have come around through that. And there have been some states where the those states that have Macs that don't participate in Mol DX have continued to pay for PCR testing using a combination of codes. One of the codes that gets used frequency frequently is 87798, and it has a MUE or a medically unlikely edit assigned to that of 13. So a lot of practices were testing many more organisms than the 13, but so the knowing where the MUE was, practices were using a units of you're using units of 13 for 87798. Then we have another code that tests for Candidia species, the 87481, which is an amplified probe technique to test for candidia, that has an MUE of five. Some people were using that at five, testing for multiple species. We talked at one point in time in the earlier part of the year, I believe it was in 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 rack audits that were 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, which were really driven primarily for 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 for that organism. So if you had multiple organisms in, let's say, a sexually transmitted infection panel, and you were just looking for yes, it, yes, you have it, or yes you don't, and that result tested multiple different organisms. The 87800 or the 87801 was the right code for that under CPT guidance. Well, the NCCI has had a directive in the NCCI guidance for quite some time that is that actually runs counter to the CPT interpretation. And its focus is on the actual test performed. So it basically says when multiple procedures, multiple methodologies, or multiple kits, so it's procedures, methodologies, or kits are used to evaluate multiple infectious agents, then your reporting should be equal to the procedures, methodologies, or kits that were used to perform the test. When we started looking a little bit deeper, and not every PCR test for UTI is set up the same way. So this is when we look at it with through this lens, which now has become the solidified argument from CMS, basically stating we are no longer accepting the CPT definition. We are driving the reimbursement definition from Medicare to get a bill for if it's an individual test real one or a test for an individual organism run with a kit that only tests for that organism, then you would bill that kit or 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, and you're testing that, and that multiple organism result comes out, then CMS is now guiding for the use of the 87800, and that is for a direct probe, or the 87801, which is for the amplified probe. So we've seen, as we've looked through all of this, different organizations that maybe they use different testing kits or methodologies and individual probes to test by organism, in which case the billing of 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 to Medicare because so many other groups are testing for multiple organisms with individual or with grouped probes and detection. So they're looking at how many different kits or methodologies or procedures are being run and asking for reporting of those grouped tests under most groups are using the amplified probe, so the 87801. So if you had tested for three different antibiotic resistance markers as well as two different organisms, let's just say, so you had five different results, and that came out of one vial with a specific set of probes and test agents for those particular targets, then eight seven eight oh one would be appropriate for that those five results. If it were seven, it would be eight seven eight oh one for seven results. So each group is gonna have to really understand how their testing is done. So this is gonna take a little bit of an 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 there are many of these tests that use multiple different pools of testing to get to their end results for UTI tests results to get back to the urologist. So depending on how your test is ultimately designed, we're gonna have to look at that to figure out what type of configuration would be billed. And even though we have some individual organisms that have their own CPT code, we won't be able to report that individual CPT code now if it is run or if the results are obtained in the same kit or methodology that we're using to get the results for a second or a third organism, we're gonna have to move to the 87801 for Medicare testing. We'll have to see what the prior the private payers do. But this is a major change, and I'd like to be able to give everybody the answer of how to bill for PCR test codes, but I can't at this point in time because we don't know how your individual configurations are set up. And this is something you're gonna need to go back to your lab partners, really take a look through this, and I think develop a very coherent argument as to why you're billing the way you're billing. I'm billing maybe three eight seven eight oh ones and then maybe eight seven four eight one with a number of units depending on how I've grouped my organism and how I can order and test those particular organisms and their resistance.
SPEAKER_02So when you you mentioned moldy x versus non-moldy x, what if you're in a non-moldyx state, this is the guidance that I mean this is impacting the non-moldy X states in this way. What about the moldy X states?
SPEAKER_01I think the moldy X states, we're still looking for that Z-code operation. Now, if the testing comes through, because in those moldy X states, it's less than five or that constitute a panel. So if you're billing 87801 times three, could that now be considered a panel that would be underneath the LCD or the that is currently published? That's a that's something that we definitely can consider. But it is a multi-organism test. Are they going to look at that at a as a panel or not? Are they looking at it as the units that are being done? And certainly I think we've seen 87801 as a code that may be used in a moldy X state. So that may open up some of the moldy X states, but it is something that I really don't feel like I have enough information to say yes right now. I've have enough inch information to say maybe.
SPEAKER_02And have you seen any Z codes come out that that are being paid under that have been paneled and paid, or you st it's still they're still forming the Z codes?
SPEAKER_01I haven't seen necessarily 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 is what they pers what you can pursue through CMS with a proprietary lab. So there's there are those options and opportunities out there for the use of a PLA, but we still have the Z code issue for the Moldi X states. And I'm not yet aware. I know there were some applications in, but I haven't seen the results yet that an actual Z code has been authorized with Mold X for UTI.
SPEAKER_02And we're talking the payment for each one of these is $35.09. Is that correct? So what was paying if you were getting paid $138798, that's $3509 times 13 versus what's coming out now is the I think the max that we're looking at is what four or five. So so that's a big change. And and then I also want to point out that the eight seven seven nine eight was for was for each organism. That's the way that this definition reads. And so that's why that that's why the guidance from the NCCI, which talks about if you're running one probe with one kit, I mean an amplified probe with one kit and it detects most multiple organisms, that's the eight seven eight oh one.
SPEAKER_01And Scott, that one actually pays 7020. Not the 87801.
SPEAKER_02So 87801 pays.
SPEAKER_01Yeah.
unknownOkay.
SPEAKER_02So the 87801. But the other ones are 3509, the 87481, and the 87798.
SPEAKER_01They are. And again, we were basing all of the information in the way that that reporting really was or should have been done was based on the CPT definition. So that CPT definition was valid. But obviously, the interpretation of the NCCI rules that are published. And then actually recently, Battle actually last year clarified on some web posts on how to bill uh multi-organism infectious disease panels as a general guidance tool came out on the Macs that are not Moldiacs. And it look, it really appears that Medicare across the MAX have been looking at the overall AI interpretation of these things, of these things, and the interpretation and the letters that we've gotten back from CMS in the form of denials, RACs, and UPIC audits have changed over the past few months. It used to be a focus primarily on medical necessity and running those that number of tests on patients. Now it appears that they've generally agreed that if you're selectively running these tests on patients that have maybe they're symptomatic and they're they've been on antibiotics, or they've that there's there's you need more than a culture and sensitivity and a UA to treat your patients based on their presentation. So that was the medical necessity hurdle that we needed to get over, that a lot of folks did. So it's certainly not something you can run in place of a UA. It's not something that you would run just blanket on in place of a culture and sensitivity. There needs to be a reason to run this extra PCR test. So that was that first argument we dealt with. And then as we saw this evolve, it's really now coalesced around the NCCI argument. So what we're recommending to folks 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, um, how many that is being used to get your results. With that, once you have that information, for those tests that you're in the denial side of the process, so Medicare is denied them. What we're going to recommend is that instead of appealing those denials, we actually submit a reconsideration with the new appropriate coding. And you'll want to have some backup information as to why you made those changes to your coding going forward. Then to prevent racks or UPICs and lookbacks, you do have the opportunity to go back and correct claims within the last 12 months sent to Medicare. And that's the other thing we've got to consider. If you're in a current RAC audit or a UPIC audit, it's one of those areas where we're doing a little bit more research, but certainly explaining why you build what you build, because you're now under an audit and you a reconsideration is something that you've got to consider. But we also have to consider the appeal of that claim as to how that balances out. And so 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, go ahead and submit a corrected claim, or do you accept the findings and then go back and rebuild? This is one of those questions that was overall not responding to a RAC audit has been something over time that we've felt was not a good thing. It actually is tracked within the record. And certainly, given the proposed home health service rule, which could allow Medicare to go back to any point in time in which you were or a proven Medicare violation occurred, that you could get kicked out of Medicare. This is something that 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 what's the best advice with that moving forward. Ray, any comments, questions?
SPEAKER_00One one quick question, Mark. You mentioned private, and you need to find out what they're doing. But if somebody has a private payer that the payer hasn't posted, how they handle that, do you recommend them using the Medicare or do you recommend them using CPT?
SPEAKER_01Well, I can tell you that 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. So 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 received it? So let's say it's processed and it's 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 on loosely on Medicare guidelines as the directive as to what processing rules are used by those entities, with Medicare going back, the potential exists that the private sector could go back and do those takebacks. So that's the thing I I worry about with all of this. Is what are the take backs? Getting paid is one thing. So you could probably still get paid using those current methodologies. And maybe the right answer is go ahead and keep going and save your money because the takebacks may be coming and you can wait for the take backs, or maybe the private payer is going to publish a rule moving forward. So it's a little bit of a gamble. Given what we're seeing in the marketplace and what's going on, it's definitely a gamble.
SPEAKER_02All right.
SPEAKER_01So it's we've always said just because you got paid didn't mean you were right. Now it's I mean, it's actually 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. And it happens with high volume procedures. So if you're running high volumes, you definitely want to prepare for the fact that could be an adjustment coming down in the future. Ugh. All right.
SPEAKER_02Okay, well, let's move on to our next topic.
SPEAKER_01This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitomycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.
SPEAKER_02Let's talk about the proposed RVU changes. Winners and losers. And what'd you find, Mark, in the analysis?
SPEAKER_01Yeah, so digging deep. Now, when I run this on a lot of times what I do from year to year is take a look at changes that are greater than 5% up or greater than 5% down, and we highlight those for you. Now, we did this on just the RVUs. So when we add in the conversion factor and the effect of 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 5% and add a few more into the mix when we do it based on fees. But we started off with the RVU side of the equation. And we really, in the end, had very few codes that had RVU adjustments that were 5% up or 5% down. The one that I and I'll just do these things numerically as we go through this. So number one was the 51715. That had a 284% increase in the RVUs. So this is the in-office version. So this is the non-facility rate that is going up by 284%, almost 285%. The Medicare payment for that code, which includes one bulking agent vial, is 1,332.36 as the national rate. That's the proposed using the current conversion factor. So that was a big jump. And that was, as we discussed last time, because they've actually rolled the bulking agent or at least one ML of the bulking agent into the cost of the non-facility practice expense and how they calculated that. So that was one of our ups. And when we discussed the TC changes, the technical component changes, you can imagine the codes that were affected because of the recalculation of the technical components, Eurodynamics, the technical components look like the RVU drops are in the 5% range. The total components overall are more in the 3.8s and the fours. As far as a reduction, so we'll definitely see some reductions in Eurodynamics reimbursement for next year. And when we put in the dollar value, we'll probably have a few of those on the 5% down range for most of the Eurodynamics. Then in the prostate biopsy space, we mentioned that we had some new codes and or code changes for prostate biopsies. There were some corresponding increases that were close to 5%. So we'll put it as noteworthy. And obviously, when we put in the conversion factor, those increases will not be over 5%. But we do have some changes in the prostate biopsy codes, once again, and some verbiage changes. And again, I think what we'll do on these is alert you to the fact that we do have some bumps in the 55707 and the 55708, which are your transrectal and your transparineal regional biopsies, one with fusion and a targeted lesion, one without. We've got a new code for the each additional biopsy, whether it's transrectal or transparineal, that's fusion guided, that will go over with you. And then we've got some changes to the fusion initial biopsy codes that we're going to need to work with you on to get the actual appropriate use of that code. And then we had a couple codes deleted. So we'll come back to some of that of 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 as far as documentation and templating. But know that we did see some increases in the initial codes and some decreases for those each additional lesion target codes. But we did see a big increase in the each additional lesion for the in bore. So those are some of the changes that we're up against that we'll see for the prostate biopsies. We also saw at least some changes in the radiology codes that we use frequently. Not much of a change for most of all that is done by urologists relative to ultrasounds and diagnostic ultrasounds. I think the 76872, one of our most common, is really not changing very much. It's about the same across the board. And then we didn't see our big bumps or any big bumps to any of the EM codes, but we did see some slight drops in the new codes for telehealth. Not much, not a lot to phone home about, but we certainly didn't see any bumps. And ultimately, these are not going to affect your Medicare reimbursement for telehealth provided under Medicare, which are going to continue to be reported using the standard EM codes. So they're there, but not much of a change for any of that stuff. So we're okay with our EM and our telehealth moving forward.
SPEAKER_02Ray, do you have any questions or comments? No, no, nothing to add. So all in all, that doesn't there's not a lot of huge movement in the in a lot of the urology codes there, from what you s mentioned, except for the bulking agent code. Other than that, there wasn't a lot of movement or a lot of changes going on. That's correct.
SPEAKER_01Not a lot of not a lot of shifts overall. We did the one thing I forgot to mention is we did see a decrease in the facility payment for the 5571. And that was the that's the biopsy code. There was one other code that I thought I saw, but I guess I hallucinated that one. So that is not yeah, not a lot of changes, not a lot of big changes, we'll say a lot of little changes. And then, 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 gonna happen.
SPEAKER_02All right. Okay, well, 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 forward slash PRS network. Also, we want to thank Eurogen, manufacturers of Zesduri and Gelmido. And if you want some more information on gel mito or zesduri, you can go to gel mito.com or zesduri.com. All right, let's get some final thoughts. Any final thoughts today?
SPEAKER_01So one is obviously the PCR side of this is gonna be an ongoing saga for a little bit. And those of you who have been using PCR testing, you 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 what our best steps. So that would be worth contacting us to see if we can help assist with those issues going forward. But it's definitely time to make a change, unfortunately. And consider the consideration of going back and fixing things in the past is also a strong one that we need to do to justify what you're doing and picking dates based on what you can affect versus everything. So that's one. And then the second other thought on all this is yeah, we'll keep digging through the RVU structure that's there. Obviously, not nearly as much activity as we had last year. And goes back again to when you asked me what was this final rule? And I would say mediocre with the exception of the modifier 25 proposal.
SPEAKER_02All right, Ray, final thoughts.
SPEAKER_00Well, I hope everybody appreciates the depth of understanding that 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 make it happen.
SPEAKER_02You're welcome, and 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. 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 information about our seminars in Las Vegas in December and New Orleans in January. Also, PR at Prsnetwork.com forward slash urology hub. We are adding more and more information about urology coding categories as well as products used in urology, how to get paid for those particular products and for those services, procedures, and services provided for those different urology categories. So want to make sure that you are aware of that. That's a great resource. We have vetted that information. So a lot of times AI isn't giving you the right information, but you can look up on the hub and make sure, verify all that information. Okay. And then finally, I want to alert you if you're listening to this before July 30th, 2026. We are having our monthly webinar at 1 p.m. Eastern time. And for those who attend live, you can get a free DN pocket card and wall chart. Mark's going to be going over what it takes to make sure that you're capturing all the information you need to capture when you're using all the new technology, the AI, ambient listening, scribes, etc. And we also have a special guest from ModMed to help with that as well. All right. That's all for today. Thank you all for listening. Take us out, right?
SPEAKER_00Happy coding and building.
SPEAKER_02Thank you for listening to the Uralogy Coding Remembers Podcast, where we help Eurofits understand, maximize income and efficiency, so there's time and energy for patient care, and a happy life. Special thanks to our painter for the music today. You can find Facebook on Spotify under his record label YouTube.