Urology Coding and Reimbursement Podcast
Urology Coding and Reimbursement Podcast
UCR 299: Listener Questions Answered — Billing for Radiological Services with Office Visits, Stone Diagnosis Coding, and Modifier 25 Denials
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
August 7, 2026
In this episode, Scott, Mark, and Dr. Ray Painter answer three reimbursement questions involving common—but increasingly scrutinized—coding situations. First, they discuss when a urologist can separately bill the professional component of a radiologic service such as retrograde urography on the same day as an E/M service, including the documentation requirements and potential conflict when radiology also bills for the interpretation. Next, they examine a ureteroscopy denial caused by an inconsistent diagnosis code and explain how to properly distinguish kidney and ureteral stones with and without hydronephrosis. Finally, they tackle another modifier 25 denial and explain why simply citing NCCI rules in an appeal may not be enough—the documentation must clearly demonstrate the significant, separately identifiable E/M service that supports the modifier.
PRS Coding and Reimbursement Hub
Botox LCD Alert
Free In-Office Prostate Biopsy Calculator (Suppoted by UC-Care)
PRS Coding Courses
For Coders, Billers, and Admins
Join the Urology Pharma and Tech Pioneer Group
Empowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.
https://www.prsnetwork.com/joinuptp
Click Here to Start Your Free Trial of AUACodingToday.com
The Thriving Urology Practice Facebook group.
The Thriving Urology Practice Facebook Group link to join:
https://www.facebook.com/groups/ThrivingPractice/
On this episode, billing for radiological services in conjunction with office visits. Also, diagnosis coding for stones. And finally, Modifier 25. Stay tuned.
SPEAKER_04Today'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 healthcare by placing doctors and patients at the center of care.
SPEAKER_03Welcome to episode 299 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host, Mark Painter, Dr. Ray Painter. And on today's episode, we're going to answer some a few more questions that came in. They're great questions, and it's always interesting to see what's happening out there and what's the latest in what are the payers doing and what are the questions that are coming in and what are they denying? And what are the different things that you need to know and you need to make sure that you're doing in order to get paid for the services you're providing? All right, let's go ahead and get started. We have the first question is a blue cross blue shield denial, and it's dealing with code 74420. And the denial was this service slash included in the allowance for another service or claim. And the question is: should this be appealed or should the 74420 be adjusted off? Please provide rationale. Thank you. And the 74420 is Eurography Retrograde with or without KUB. And Mark, you want to give a little more color in why they are asking that question? What did they build with that?
SPEAKER_04So there's so we've got a few things, and I I'll tell you, as we go through this question, we need more information really to fully answer this question. But we do have a couple of different issues that we can talk about. So let's assume first that this was done in an office setting. So essentially it was probably build with an EM code, because that's where the bundle comes into play in most of these cases. As what we're following is what we saw with United Healthcare coming out about the interpretation for any radiologic service needs to be clearly documented as separate from any ENM service that is provided on the same data service. So they're going to deny the global based on the assumption that the 26 is part of or the professional component is part of the ENM. And the practice could go back and use a 74420 TC, and it probably wouldn't be blocked as bundled. So that's one of the options that's out there. Now, that would be if there is not a separate deep level interpretation, like a radiologic report, of the 74420 read. So that's one of the issues that could be that blocker that's there. Now, if it's in a hospital setting, billing the 74420 without a 26 modifier would drop it out as bundled because the hospital, the facility, gets paid for the technical component typically for the radiologic services that are out there. So just that 74420 as bundled could mean a couple of different things. And it looks like this was billed in a hospital setting. Yes. And they did build a 74420-26. So in this particular case, you've got two other issues that we got. But let's go back to the first issue. Basically, I want to remind everybody that when United Healthcare put out their policy, that they were going to start denying the interpretation of a radiologic service as part of the EM. What they're really talking about is that the ENM code has, of course, a scoring under data for interpretation of an image. So there's what they're saying is if you're just doing an interpretation of the image as part of your ENM, they're not going to pay you the professional component on the same date. That's double dipping. So in order to get paid for a global 74420 in an office setting, you need not only to have performed the service, but somebody needs to have dictated a clear and separate diagnostic report. And that needs to be included in any appeal as to what's going on. Now, in the hospital setting, it does look like this claim was billed with a 26 modifier. So our issue isn't incorrect coding. This is a fishing expedition to explore the exact same issue, but in the hospital setting, with one additional caveat. The other caveat is did the radiology department bill for the professional read of 7442026, in which case it's bundled into their service because it's already been paid to the radiologist. So when you're in a facility setting, you've got to check both, that you have that separate dictation that clearly demonstrates that you did a separate and distinct diagnostic read of the image and dictate that full report. Not that it's focused on the issues that you're managing as part of the ENM code, because you do have an allowance in the ENM code to help support that 99222, that is the separate interpretation of that image that they would count as part of the ENM code. So in either case, the separate dictation is required. And ultimately, in the hospital setting, you're going to need to make sure as well that your radiology colleagues didn't bill for that service separately.
SPEAKER_03Ray, comments, questions?
SPEAKER_00Martin, back in the old days, we used to tell them if they were going to charge for that, they needed to get their bill in fast. They had to be before the radiology. Is that still the case, or the radiologist pretty speedy these days?
SPEAKER_04I would say that it is difficult to get things in ahead, but it's not impossible, and it depends on the radiology department as to how good they are. So they are going to pay the first bill in for the 74044026. And it's always better to coordinate with radiology than just speed them out and upset them and hurt your relationship. So it's one of those things that having that discussion should be part of the problem. And as far as this particular denial, I'd look at both, right? Number one, did I have a separate dictation? If I didn't, then I'm not going to appeal it. If I did have that separate dictation, my next step is did radiology bill for this? So now I'm checking with radiology. But if I don't have the paperwork to support it, I can't appeal it anyway. So if you don't have the report, there's probably no reason for you to re-bill this code at all, because it's going to take an appeal to get it paid. If you've got the report, check with radiology, see if they got paid. And now you're in a discussion with radiologists, the radiology department to decide if they want to retract their bill and allow you to bill, or if maybe you can fix this going forward, in which case you wouldn't appeal it, or if they're willing to retract their bill and you can bill for it then with it under an appeal. So documentation first, then coordination.
SPEAKER_03What's the likelihood of a radiology group or department to agree to that? I mean, they're reading it anyway, right? They're putting in the work, and you're doing the same work that they are. Why would they give that money to you versus they did the work as well?
SPEAKER_04That would depend to me on the negotiation skills of the urologist and the general attitude of the radiologist that you go through that. I mean, the argument overall is that the urologist doesn't always get the report from the radio from the radiologist. So their read is really worthless to the treatment of the patient. But the on the counterside of the the equation is the some urologists like to have the radiologist radiologic read to get a second opinion for the care of their patients. That's a balancing factor that's there. So, and then of course, there is the radiologist out there trying to hold his job and get his work RVUs. So that may be something that they can hide behind a hospital policy or a bunch of different things. So you might have a nice radiologist, but a department that's trying to protect their folks, there's just a lot of politics that goes into play when you're in a hospital situation like that.
SPEAKER_00We might add, Scott, that in this case, CMS is on the side of the urologist. If the urologist read this at the time they were doing a procedure, in other words, they put in a stint at this point, and if this was read at that time that the procedure was put in, the CMS would like to see the individual at the point of service get paid.
SPEAKER_04Yep. Then again, I'll add the caveat that the documentation has to be clearly separate and fully baked from a radiology report standpoint.
SPEAKER_00Absolutely.
SPEAKER_02Okay, let's move on to the next question.
SPEAKER_03Next question came in and it states they are denying as they are denying 52356 as CO11. The diagnosis is inconsistent with the procedure, but they paid for the other two codes on the claim. Not sure if there is another code that we may use. And what was billed was the 99222-25 with the diagnosis code in 13.30, the 52356-RT with the same diagnosis, and the 74420-26 with the 13.3. So I think first let's give everybody the alphabet soup, the codes and descriptions of everything, and then Mark, you want to take us through it all.
SPEAKER_04Okay, so 13 and 13.30 is unspecified hydronephrosis. That works for the hospital visit, which was a level two, which equates to a level four inpatient or outpatient visit, that 99222. The 25 applied appropriately, paid, but I will say paid with a denied surgery, so there's no global. So that might be an issue that pops up later as you go through the appeal side of the equation, which is our next question, modifier 25, and what we're seeing on that. And then the 74420, of course, for the KUB that we just talked about. So, number one, we have talked many times before that unspecified is a diagnosis code that is not appreciated by the payers. So now we look at the actual denial. And one of my questions would be: How would you do a 52356 if there wasn't a stone? In which case, my immediate recommendation or question would be why didn't you use an N20.01 or two? That's the diagnosis for stone. So that could be one option to switch that over to an N20, either 1, 2, 0, 1, or 2, depending on where the stone is located. And then the other one that's available is the N13.2, which is hydronephrosis with a renal and ureteral calculus obstruction. So that's another potential that's out there. So you've got a few different options to look at that would state clearly that the patient had a stone, which would be a reason to use a 52356. This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitamycin 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_02Ray, comments, questions? No, nothing to add.
SPEAKER_03Good comments. So which which code, which diagnosis code will work better with the 52356? The N13.2 or one of the N20 point codes?
SPEAKER_04Okay, so this is where you might be misled a little bit by the description. N13.2 is hydrophrosis with ureteral and renal calculus. But if you actually drill down from the N20.0, the N20.1, the N20.2, it specifically says that in the excludes category that N13.2 is a that with hydronephrosis, meaning calculus of kidney with hydronephrosis should be N13.2. So if you've got both a stone and hydronephrosis, the better document documented diagnosis would be the N20 point wherever the stone is, either kidney, uter, or both. So N13.2 is the one that actually works better with hydronephrosis and should be the help that's there.
SPEAKER_03So if they have hydronephosis hydronephrosis with the stone and they do the 52356, then the diagnosis and the stone's in the ureter, so then they use which diagnosis?
SPEAKER_04Is it the stone's only in the ureter? Yep. N20.1 if without hydronephrosis, N13.2 with hydronephrosis.
SPEAKER_03And it doesn't matter if the the stone is just in the ureter or the kidney within 13.2.
SPEAKER_04That's what that's the directives that we see from the uh the inclusion notes within the N20 series. So you would be justified using it for either the kidney or the ureter or both.
SPEAKER_02All right. Ray, any anything to add?
SPEAKER_01Nope. Nothing to add.
SPEAKER_02Okay. All right.
SPEAKER_03Let's move on to the final question. The final question is Aetna Medicare is still denying the office visit. We've already done a dispute with them, which they denied it, which they denied, and it has the modifier 25 on there to separate it from the 52000. So what was billed was the 912 99214-25 with a diagnosis of N40.1 and the 5200 with a diagnosis of 33.8. And the verbiage used in the dispute that was already sent in is I submitted a dispute with procedure code 99214-25 denied as incident two 5200. Per NCCI edits, 5200 includes 99214. However, can be a bundled unbundled with the appropriate modifier. Unbundling allowed with an appropriate modifier code 99214 is included in 5200. 99214 may be unbundled from 5200 if you can justify the appropriate modifier. If you are unable to justify the use of a modifier, you may only bill 5200. If you bill both, 99214 should receive the modifier. And I have attached the supporting documentation and ask that the claim be reprocessed in a favorable manner. Okay, I guess let's what do we need to look at the diagnosis? Just make sure everybody understands which codes were being billed with the diagnosis codes. So we got the 99214, which is the level four office visit with the N40.1.
SPEAKER_02And the N40.1 is EPH with LUT.
SPEAKER_03EPH with LUTs. And then the SIST, the 52000 was billed with the 33.8. The R33.8.
SPEAKER_02Which is retention. The retention. So okay.
SPEAKER_04How do you break this down? Well, so I think the argument is very that was submitted was very factual from a coding standpoint. That's absolutely true. Which is noted as I have attached the supporting documentation and asked that Aetna reprocess this as in a favorable manner, but really not explained. What you're justifying here is probably not the NCCI edits. Those they know. That's why they push the denial through. So my recommendation would be that any further appeal, if you want to push this up to the independent reviewer, which isn't Always successful, but certainly worth a try, depending on which payer it is. Really focus on why that modifier 25 was significant and separately identifiable. You've got a different diagnosis, but LUTS could include retention as part of that LUTS side of the equation, the BPH with LUTs. So are you doing something really significant and separately identifiable from the SISTO on that day? That's the focus of the denial. And if they've reviewed the note, that's where they're coming through with that. So I would, if I were going to appeal, I would want to make sure that my note really supported that this wasn't a quick, boy, you've got retention, let's do a sister and see what's going on. You've got BPH, and and we maybe we know that or we don't. So it's ultimately we need to think about a plan going forward. So it's really got to be more separate that you did a significant service, guy comes in, maybe you're following him for BPH with LUTS. You're not only worried about the retention, but you're also worried about uh what else is going on with that particular patient situation. You develop a full plan that is for treatment of that BPH with LUTS, not just that you resolve the issue that day. It really needs to be that full separate and significant identifiable EM that's not part of the global of the system, which means they're okay for the procedure, they got the procedure, they're told what the procedure results are, and that maybe another appointment scheduled. So you want to make sure that you're really supporting that full significance separately identifiable, because I that I think that's where that denial is focused on. Not that you coded it incorrectly, but that the documentation didn't support your coding.
SPEAKER_02Questions, comments?
SPEAKER_00Oh, just to emphasize what Mark said. In the follow-up from the SISTO, if you sit down and set up a plan of action, started on medication or set them up for surgery or whatever, that's what your documentation should show to show that was a significant and separate service that was provided in the ENM. And not just, hey, you need a SISTO, we're gonna do it. Yep, you had one, you've got VPH.
SPEAKER_02That wouldn't get you paid. Okay. All right, let's wrap this episode up here.
SPEAKER_03Uh, we want to thank our sponsors for this episode. First of all, we want to thank ModMed. If you're in the market for any HR or a practice management system, you can go to modmed.com forward slash PRS Network for specials for our listening audience. Also, we want to thank Eurogen, manufacturers of Zesdury, and gel mito. If you want more information, you can go to gelmito.com or zestdury.com. Okay. Well, let's get some final thoughts here on today's episode.
SPEAKER_02Mark, what are your final thoughts?
SPEAKER_04Well, I think it was, I think we saw a couple of things today that were out there. We had three different topics, and all of them point back to our standard beat the drum documentation. Making sure that your documentation supports the diagnosis code. You're really looking at all the language available in the diagnosis coding and making sure you're specific in your documentation. That one was a coding issue that we know of. We don't know about the documentation issue there, but definitely understand that, and that's a flag that you could put for your RCM team to catch those mistakes. But the documentation issue of making sure you had the stone and the stone location is key, as well as the size, all of that stuff needs to be there. And then your documentation for your radiologic service that needs to be separate and diagnostic in nature. And then finally, the modifier 25, a recurring theme and probably the most talked about on the urology coding and reimbursement podcast of any one topic. Make sure that modifier 25 is clearly supported. I mean, it is the most widely abused modifier in CPT coding, and it is under Steve microscope. So, and we'll put it under the AI microscope. So make sure you've got clear, separate, significant identifiable documentation. And then, of course, last week we talked about the proposed rule, which is of course one of those things that we're gonna have to keep an eye on. So is it gonna be a lesser valued modifier 25 or not? Is still coming up. So, but it's still value, even if that goes through. So the documentation requirements will not go away.
SPEAKER_03Final comments.
SPEAKER_00Well, if Mark didn't mention documentation, I will. Only kidding. But the other thing is that he made a big point of is when you are appealing, be sure you are using your documentation to support the code or the modifier instead of just quoting the rules. So your documentation has to be there, and then you have to argue that it's there.
SPEAKER_02All right. Okay, well said.
SPEAKER_03If you go to PRSnetwork.com, right there on the homepage is a button to register for the seminar or get more information and pricing. Also, the PRS Urology Coding and Reimbursement Hub is available at PRSnetwork.com forward slash urology hub. And on the hub is where you'll find the categories of various urologic services so that you can look up how those are coded and then also specific products associated with those categories. We're improving that every week, so we encourage you to check that out and make it a part of your search when you're researching various coding and reimbursement options for different categories. All right, that's all we have for today. Thank you all for listening. Thank you for listening to the Uralogy Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to Fellow Painter for the music today. You can find his music on Spotify under his record label.