Key takeaways from this episode

• Get a Medicare ABN for services that are covered sometimes, such as excision of a benign lesion for scrotal sebaceous cysts, but not for services that are never covered, such as shockwave therapy for erectile dysfunction. Without a signed advance beneficiary notice, Medicare will not let you bill the patient when a "sometimes covered" service is denied as cosmetic.
• Charging limits differ by category. With an ABN on a sometimes-covered service you may still be limited in what you can charge; for a truly non-covered service you can charge what you want.
• "No symptoms means cosmetic" is a reasonable first step, not the whole test. Asymptomatic prostate cancer is still prostate cancer; what matters is the disease state and what the documentation supports. Advice that removal is optional for appearance points to cosmetic, while "could become infected" lands in a gray area that may still be non-covered as preventive.
• For borderline cases, run a predetermination against the patient's specific policy using the CPT and ICD-10 codes, and have the coverage conversation before scheduling. Not every payer offers predetermination, but where it exists it is worth the extra effort.
• Collect from the patient before the service and refund later if insurance pays. Yes, you can collect up front when an ABN is signed; push the claim through promptly because you have about 60 days to refund an overcharge.
• A payable diagnosis (a symptom or disease process) at that visit should drive coverage, but payer rules are blanket and shotgun, so expect to appeal. Decide up front which claims you will fight; if you "go fishing" on a claim the payer probably will not cover, have the ABN signed and tell the patient you are going to try.
• Consider a separate cash-pay entity for clearly cosmetic or non-covered services, and do not be afraid to talk to patients about cost before the visit. Payment conversations before the service are always easier than afterward, since patients with large deductibles often assume insurance covers everything.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 267, recorded November 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Covered, sometimes covered and non-covered: sorting out benefits before the service

[00:00] Scott Painter: On this episode: how do you deal with covered versus non-covered procedures? Stay tuned. Welcome to episode 267 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-hosts Mark Painter and Dr. Ray Painter. Today we want to cover covered procedures and non-covered procedures, and how you deal with those issues. We saw a recent post in the Thriving Urology Practice Facebook group where McHale asked about excising six to eight large sebaceous cysts from the scrotum and how that was coded. There was a comment in there that said, if there are no symptoms, cosmetic procedures are self-pay; charge what you want up front. So, Mark, do you want to talk a little bit about covered versus non-covered and how this all fits together?

[01:00] Mark Painter: Yeah. This ties in a lot with benefits. When we look at benefits overall, we really have to consider what the payer is and what your policies and procedures need to do to match. The point brought up on the Facebook post is a good one: essentially, were these sebaceous cysts causing any issues? Certainly they had the cysts. There's an argument that could be made that those are not healthy for the individual to have; they could become infected. There are a lot of things there. So that one rocks that borderline of cosmetic versus not cosmetic, which has been a struggle throughout.

But what we're seeing are a lot of payers really looking at the benefits package they're offering and coming up with things like, standard, impotence or erectile dysfunction is not a covered diagnosis under a lot of the insurance plans out there. So we certainly have visits to the urologist for erectile dysfunction, where that's the only thing the patient is coming in for, that the payers aren't paying for. Then there are those quote-unquote cosmetic procedures, and procedures that are considered experimental, like shockwave lithotripsy for treatment of erectile dysfunction. We have a lot of these things in urology.

Ultimately, when you're trying to figure out when to charge the patient and when not to: if you've got an idea up front that the payer is not going to cover this, or you think the payer might not cover this, it is definitely pre-service that you want to have a discussion with your patient, making sure they understand that this may not be a covered benefit under their plan. A lot of things you should be able to find out if you go through a prior authorization. And if you have a question, if it's one of those borderline issues, this might be worth the extra effort of going through a predetermination. The predetermination differentiation here allows you to enter your codes, including your ICD-10 codes, and bounce them against the patient's specific policy. Not all payers have this, but if they do, this is one of the steps I'd recommend you take.

You also have to consider where your contract is, and this is going to be a secondary issue as you have that conversation with your patient. If the service being provided is non-covered, does it require any paperwork? With Medicare, typically, if we have a service that's covered under some circumstances but not all, like an excision of a benign lesion, which we would typically use for sebaceous cysts, you'd be well served to get an ABN, an advance beneficiary notice. Excisions of lesions are in fact covered for medically necessary purposes. But if you end up with a benefit issue, meaning the plan doesn't pay for it because they're going to consider it cosmetic, and you didn't notify the patient and have them sign an advance beneficiary notice with Medicare, you won't be able to charge them. So you need to make sure you understand your options relative to your contract for those particular codes you're using. Now, if it's something like shockwave lithotripsy for treatment of erectile dysfunction, that's considered non-covered, and you don't need an advance beneficiary notice.

Then you've got the other differential relative to the coverage and benefit side of the package. If it's covered sometimes, and you've got an advance beneficiary notice signed by that patient, you may still be limited as to what you can charge for that particular procedure, whereas for a non-covered service, you can in fact charge what you want.

Now, there are some practices that have essentially carved out a separate taxable entity to focus on cash-based services. We've seen this with a lot of urology groups. They provide a number of cosmetic services to their patients, and it's very clear when they're in that particular entity that they're coming in to get services provided in a fee-for-service, direct, cash-from-the-patient entity that doesn't actually participate with Medicare. Those entities are handled somewhat differently. So you really need to think about how you are going to approach these procedures before they're performed, and you want to have somebody in the mix who is actually pulling the trigger on those benefits research issues before you schedule the patient, and design your approach based on where those rules are for that particular patient and their coverage at the time.

Is "no symptoms means cosmetic" a good litmus test?

Scott: Well, I've got a couple of questions, but Ray, do you want me to go first, or would you like to ask a couple of questions?

Dr. Ray Painter: I can wait. You go ahead.

Scott: Okay. One of the comments that I read earlier: if there are no symptoms, it's cosmetic or self-pay. How good of a litmus test is that?

Mark: It's definitely one that should be considered as a first step. Ultimately, an asymptomatic prostate cancer is still prostate cancer, so you want to make sure you understand the disease state you're dealing with as to whether or not it's really going to be considered cosmetic or not covered by the benefit. Symptoms are not the only measure. That's one thing to consider. The other part of it is, what does your documentation support? If these are cysts that are really asymptomatic, and your advice to the patient would be, those are just something that occur, you don't really need to have those removed, but you can if you're worried about the appearance, that kind of answer typically puts things into the cosmetic category. If you look at it from the standpoint of, these are beginning stages of or could become infected, that's when you hit that gray area, where ultimately you're trying to remove this to prevent a problem in the future. That may not be purely cosmetic, but it may still fall into the non-covered category, because it doesn't have any medical problem in presentation. It might fall into that pseudo-screening category, or preventive medicine, that is really not a part of the benefit plan.

So I would look more toward "can I leave this?" as cosmetic, as a first step, and those that are in the gray area, that's really where you want to push through the predetermination, have the conversation with the patient, and sign any necessary paperwork. I always recommend with those services that you collect from the patient before the service and refund later. If you absolutely know it's going to be cosmetic, then think about whether you have the alternative to provide those services through an entity that's really cash pay, and refer them to that entity. If not, that's where you do the paperwork, charge up front, and don't be afraid to refund the patient if in fact insurance covers it after you've done all your research, paperwork and collections.

Scott: Do you recommend collecting up front when you get an ABN signed? Can you do that?

Mark: I definitely recommend that. You've got some time to refund a patient if you've overcharged them, 60 days, so you don't want to lollygag on pushing the bills through the system, so you know when you need to get them reimbursed. But your suspicion up front with an ABN is that it's not covered. So yes, you should charge up front, and you can.

Payable diagnosis versus payer rules

Scott: Ray, any thoughts, questions?

Ray: Well, Mark, doesn't it really boil down to whether, for that particular patient and that particular problem and that particular visit, you have a pathological, payable diagnosis or not, which could be a symptom or it could be a disease process?

Mark: We actually had a couple of interesting discussions over the last couple of days with various groups involved in healthcare reimbursement, from the payer side of the equation, though the main focus was on the manufacturer as well as the physician group. What really is important in those particular cases is not always straight logic based. We've always said that logic, in some cases, needs to be thrown out the window. But on the logic side of the equation, I totally agree with you that ultimately the presenting pathology, and where the patient is on that visit that day, should be the driving factor when we look at all of these issues that could be cosmetic or could actually be a treatment.

But we also have the payer rules, and the payer rules are far more blanket and shotgun than we'd like them to be. So you may have to fight to get one of those, where with the pathology it is a treatment, with the diagnosis codes you use, and you may not. It really boils down to the fact that you've got to do your best to interpret the payer rules up front, check all the boxes you can, but then be prepared for the fact that the payer's read of their own rules may not be your read of those rules. That may require well-worded appeals to get those covered and paid, or it may be that the patient is the right way to get paid for those services. I wish I could give you a one-size-fits-all answer. In some cases it's there, where we have obviously non-covered services, or it's not on the borderline: it's definitely going to be cosmetic or screening and not part of the benefit package. But we always have those that fit on the borderline, and that's where you essentially protect yourself. That's a CYA: collect, document, and then determine how much you're going to fight for the patient.

Scott: That's a very good point.

Ray: In these gray areas, I've always tried to come down on the patient's side. So you do have to make that determination up front as to where it should be paid, taking into consideration what you've done, what you can bill, and the payer rules as you know them, and what they shouldn't pay. Every now and then you go fishing with "they shouldn't pay," just to see what the payer does. But in that case, you have to have the ABN and charge them up front, and just tell them you're going to try. Now, if you know that it should be paid, then you charge it. You've got to have a payable diagnosis and a payable code, and in that case you fight. That's the one you would appeal, if it needs appealing.

Scott: And would you get the patient involved in that?

Ray: If you need to, if you can. That doesn't help a lot, but I had one case, the first case I ever took to a judge to decide. I thought I was really doing the profession a good favor by getting my engineer, detailed patient involved in a case where, in reality, he should be paid, but the rules set it up so that he wasn't. We won, and I really thought I had done something, until I finally figured out that when you win one case like that, you've won one case.

Mark: In the end, getting the patient involved does help when we see arguments occur. They do have a little bit more pull with the insurance companies than a physician group does. Not every patient has the same capabilities to assist, nor the will, and that workload is there. So you have to balance when you bring the patient in. And as Ray mentioned, it is one case at a time with a lot of these things, because what we're talking about is not the average case. That's always another thing to consider as we look at everything.

Scott: Yeah. And if you look at that, it comes down to, and probably what the insurance companies are counting on, is it worth my time? A lot of that gets answered: no, it probably isn't, or yes, it probably is. But that's what the insurance companies are counting on, that you're saying, nah, probably not worth my time.

Sponsor and seminar reminders

Scott: All right, let's wrap this 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/prsnetwork for specials for our listening audience. I also want to mention that the Urology Advanced Coding and Reimbursement Seminars are coming up really quickly. There's one on December 5th and 6th, 2025 in Las Vegas, and January 30th and 31st, 2026 in New Orleans. If you're interested in learning more, you can go to prsnetwork.com and click on the seminar registration button right there on the homepage. All right, let's get some final thoughts. Mark, final thoughts?

Final thoughts: don't be afraid to charge the patient

Mark: My first thought in all this is, don't be afraid of charging the patient. Patients are now stuck with out-of-pocket expenditures that are growing, and they're just going to keep growing. So don't be afraid of cash-based services. I know the worst payer we've got is the patient, and that's the thing that lingers in the background. But what we have found in watching practices across the country is that having the discussion of payment before the service is always easier than after the fact, because patients still come in thinking that, even though they saw they have a big deductible, insurance covers everything. They don't understand insurance. They don't understand co-insurance. So you need to have those discussions. Don't shy away from these procedures, don't shy away from treating those patients, but also don't be afraid to talk to them about cost.

Scott: Kind of like the dentist's chair, when you're sitting in the dentist's chair and you have a toothache.

Mark: Exactly. Everybody asks, hey, what's this going to cost me, doc? And they don't do that to the physician, and that's what they need to do.

Scott: We need to change that paradigm. All right, Ray, final thoughts?

Ray: Just to echo what Mark said. If you feel bad about charging patients up front, check with what your primary care physicians are doing. That's what my office did to me one time when I was reluctant to charge what I should, and I found out that I was a dinosaur. Everybody else was charging the patient when they should charge the patient.

Scott: Yeah, but you lived in the times where you were trading a cord of wood for a vasectomy.

Ray: Oh, I liked the lamb chops the best, though.

Scott: All right. That's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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