Key takeaways from this episode

• Medicare does not require modifier 25 on an E/M visit billed with a urinalysis, uroflow or PVR (51798), and appending it blindly blocks G2211. A blanket hospital or RCM policy of adding 25 to every E/M code also raises audit and takeback risk when Medicare profiles incorrect modifier 25 use.
• Employed urologists should find out whether G2211 is being stripped before billing and whether its 0.33 work RVUs count toward their contract thresholds. That is the first question to ask the hospital system, since the RVU credit affects base production and bonus calculations.
• For commercial payers such as Aetna and Blue Cross Blue Shield that demand modifier 25 with a UA, set up payer-specific rules in the practice management system and appeal to get G2211 paid alongside the 25. PRS has won this argument through the revenue cycle side: the payer's modifier 25 edit is its own misinterpretation of the global and should not block a documented, separately warranted G2211.
• If a payer has published that it no longer pays G2211, as UnitedHealthcare did, treat it as a contract issue. Appeal first, then ask in renegotiation for a cost-of-living increase plus G2211 coverage or a carve-out, and use the argument that any Medicare-based contract already has G2211 built into the conversion factor through budget neutrality.
• G2211 pays about $18 in 2026, up from $16, and applies to almost every urology visit for an ongoing serious or complex problem such as BPH with obstruction or cancer. There is no frequency limit, so it can be reported on consecutive visits for the same problem.
• Be prepared to walk away from a payer that will not negotiate. Dr. Lin has never regretted dropping a payer; analyze how much of total revenue the payer represents and whether the eligibility, prior auth and referral friction is worth the staff cost.
• Do not ignore small codes because they seem too small to bother with. Rent, utilities and staff costs keep rising while Medicare projects a 0% payment change for urology in 2026, so ignoring G2211 hands the payers a pass.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 270, recorded January 2026, with Scott Painter and Mark Painter of PRS Network, and guest Dr. John Lin, solo practitioner in Gilbert, Arizona and founder of the Thriving Urology Practice Facebook Group.

Welcome back, Dr. John Lin

[00:00] Scott Painter: On this episode: G2211 payment went up this year. Is modifier 25 bringing it down? Stay tuned. Welcome to episode 270 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and a special guest. We want to welcome back Dr. John Lin, a solo practitioner from Gilbert, Arizona. He's the founder of the Thriving Urology Practice Facebook Group. John, tell everybody how they can join the Facebook group if they have not joined it already.

Dr. John Lin: Well, thank you for the opportunity to be here again. I'd like to say that with the Facebook group I'm serving as the modern-day Robin Hood. I take from the information rich and give it to the time-constrained poor. It is a free Facebook group. Someone recently said, why can't you do it on another platform? Well, I haven't found another platform that is free, which allows you to post memes, videos, go live and share photos in a private, semi-private community, really for free. Those of you who are not members, you're missing out on a great deal of information to help you thrive and survive in today's complex urology practice environment. Back to you.

Scott: All right, well, thank you, John. We love having you on, always bringing up some great topics, and we love hearing your wisdom and advice. You brought this topic to us today, and we want to say Happy New Year to everybody, as this is our first episode of the new year. John, do you want to share with the audience what it is you want to talk about and why it's so important?

The listener question: a hospital system's modifier 25 policy blocks G2211

John: Well, as always, there's no shortage of questions in the Thriving Urology Practice Facebook group. This came from an anonymous member, actually a very educated anonymous member on coding and billing, on December 29th. He or she wrote: "I want to get some clarity on G2211. We are an employed group with a large multi-state hospital system. We began using G2211 in appropriate settings, but soon realized we were not able to bill for it because the hospital was applying modifier 25 with E/M office visits whenever UAs, or urinalyses, were run. This modifier negates the ability to bill G2211. Could someone explain the rationale for this? It doesn't seem to align with the definition of modifier 25, and we certainly aren't documenting it as such. Thanks." What do you think, Mark?

Mark Painter: Well, one, that stinks. We see a lot of institutions that develop policies that are RCM friendly. Let's say that the RCM group doesn't want to do the extra work of making decisions, which in the end pays the facility, the hospital, the whole organization less, and shorts the physicians.

The first place I would go is whether those employed physicians are given credit for the work RVU. If their contracts are work-RVU based, the G2211 does have 0.33 RVUs, which over time, using it as much as we do in urology, will make a difference on their contracts. So first I would ask that individual: are they removing it before it's billed, and is it being counted against or for your contract? If you submitted it and it's submitted correctly, and their RCM policy is such that they want to lose money, if you get the credit, that's their problem. In the end, yes, it becomes your problem as they decide that maybe they're not making enough money to continue paying you, or try to negotiate down your bonuses and your conversion factors. But that's their problem, in a way.

I will also tell you that they're using it wrong, which is really unfortunate. There are payers out there, and I can tell you we've done this through the revenue cycle side, that have required modifier 25 in ridiculous circumstances, like with a UA. But we've been able to argue the G2211 with the 25 modifier based on their misinterpretation of what a global is. So there's more than one way to skin a cat, is the way I look at this. And certainly, if they're making a policy that they're submitting modifier 25 for every E/M code, even with a UA, to Medicare, they're actually increasing the risk of an audit or a takeback as Medicare runs their profiles and looks at their incorrect use of modifier 25 relative to Medicare rules. So it's really not the right move for the billing side of the equation.

I guess I would look at this as two different issues. Number one, what's it hurting as far as your contract, and what's it doing to hurt you? That's the first selfish and probably important move. And the second is that the hospital is also asking you to go at increased risk of audit, because they are inappropriately billing for services to Medicare based on the actions of maybe one or two payers, just to make life easier for their revenue cycle management team.

Medicare rules versus private payer rules

[06:00] Scott: John, comments, questions?

John: Well, I thought this was a great question by Mr. or Mrs. Anonymous. He or she understood the nuance among the different situations and different codes. For instance, there's the E/M code interaction with modifier 25, and how G2211 is excluded from being used whenever a modifier 25 is appended to an E/M visit. And Mark very astutely pointed out that for the employed urologist, as is the case here, that 0.33 work RVUs counts. Usually employed urologists have a threshold to meet, and it counts toward meeting that threshold for base production or bonus threshold, or some sort of progressive reimbursement depending on the total amount of work RVUs generated per year, per quarter or whatever it may be. It adds up. When so much of our work is in the office providing evaluation and management services, G2211, or 0.33 work RVUs, adds up.

It's a very smart question, and this is something that we discuss at the Urology Advanced Coding and Reimbursement Seminar pretty much every single year. So I commend the member for understanding what blocks G2211, and the fact that the UAs don't need modifier 25.

Now, whenever we talk about coding and billing, we need to understand that there are Medicare rules for Medicare and then rules for private payers. For many years we've understood that Aetna and Blue Cross Blue Shield, some of them, require a modifier 25 on the E/M visit whenever a urinalysis is run to get that urinalysis paid. I think that is the conundrum for the revenue cycle team, the billing team. Do they want to build in rules when coding and billing for different private payers versus Medicare? I would figure that's a fairly straightforward thing to do in the practice management software: set up the rules for the particular private payers that require modifier 25, and then Medicare doesn't require modifier 25. That said, if you use modifier 25, that blocks the use of G2211, which contributes to the total work RVU for the urologist. So how do you overcome that? That is the problem.

Mark: Yeah. And again, one of the things we've been able to do with several of those payers that have those specific rules, not just the UA but the uroflow and the PVR, is we're still putting the 25 on there, we're still putting the G2211 in, and we're still getting paid for all of them. It does take some work to get that argument through: that this is their ridiculous payment rule, and that modifier 25 is actually not required under Medicare and therefore should not block the G2211. That's the argument you're moving forward. I'm like, fine, we'll play with your current coding edits and your adjudication edits and add the 25, but you still have to pay us the G2211. These are all services that are documented, separate and clearly warranted. Your shotgun approach to block some of these things is not my problem. It's yours.

What if a commercial payer won't pay G2211 at all?

[10:00] Scott: What about, and I know we talked about this in the past, some commercial payers not paying for the G2211? How do you work that into Mr. or Mrs. Anonymous's question? If they're trying to get credit for that in their system, and certain payers have certain rules, and you're getting around the 25 to get the G2211 paid, what if they're not paying it? Obviously Medicare Advantage and Medicare have to pay it, but for the others, is it just their rules that you have to look up, or how do you know which payers to go after?

Mark: They should be printing those rules, as United did in their bulletin, saying we're no longer going to pay G2211. Now that becomes your option: to stay within the contracted or accepted group of physicians that are willing to continue to see UnitedHealthcare patients at that discounted rate of not getting the G2211. That's a business decision, because you can get the contracts in. Unless those are printed policy, though, that's where you have the argument, and that's where we're pushing back on Humana and those particular groups that are still paying for G2211.

Then your next move, obviously, whether or not you want to just sign the contract, is do you want to push back on the contract? Do you want to try and push in carve-outs? I know that's extra work. But it is one of those areas where you have to make a decision as to what your practice is going to accept and what it's not going to accept, and what is the damage of staying in or out of network with a particular payer if they're not willing to pay you at least something that you're willing to work for. I'm not going to say acceptable. We'll just say willing to work for.

Scott: Yes. Let's go a little deeper on that, real quick, on the contracting. Let's say you want to get your G2211 paid for, if they stopped paying for it for whatever reason, and you go negotiate. Is now a good time, since it's the beginning of the year, to reach out and try to get all this done? Or does it matter what time of year? If you see it, you do it?

Mark: I'd say if you see it, you do it. From my perspective, given the lift of a contract renegotiation, the first move is to try the appeal route. Really try to get your team to use Coding Today and other things that demonstrate that modifier 25 really is not required with a 51798 or a UA. The second, then, is the contract issue. That's where you go back and you ask for a cost-of-living increase plus coverage of G2211, or any of these other issues, or push for a carve-out on your UroLift in the office. Those are all asks that can be made. And the reality is, if you don't ask, they won't say yes. They won't say no, but they won't say yes.

Scott: Very true. John, what else do you have?

Why the little things add up in urology

John: That's what's so frustrating about the practice of urology in a third-party payer system: you have to satisfy so many people. You have to satisfy the patient in front of me. Then I have to satisfy the billing and coding rules. And then I have to deal with, okay, am I dealing with a Medicare patient, a Medicare replacement plan patient, or is this a private payer? And if it's a private payer, which private payer is it? Do I need to use a modifier 25 for a urinalysis for this particular payer or not? And then you start thinking, okay, what about G2211? If I use modifier 25, I can't use G2211. How do I deal with this? Do I deal with contracting? Do I deal with the carve-out? Do I not bill for G2211, or do I just forgo the UA, because UA pays very little and G2211 pays, actually, it went up, from 16 to 18 dollars this year. That's a lot of decisions to make, and it unnecessarily complicates the situation in the care of patients. But unfortunately, those are the rules that we're dealt.

Scott: Yes, it's so true. We've said this a lot, and we talk about this at the Urology Advanced Coding and Reimbursement Seminar, and John does a very good job of pointing out how these little things add up in a urology practice. G2211 adds up significantly, because almost every visit has the possibility of G2211 in urology. There's a lot of chronic care going on, and patients are frequently with the practice, potentially for a long period of time. And we still hear people saying they're not using G2211. It's an $18 code this year, so a lot of people are like, ah, I can't be bothered. But that's just not the right way to look at the coding and billing and the rules. There are a lot of little things like that you have to pay attention to. Unfortunately, it's a complicated lot of rules and a lot of little things, but they all add up.

[16:00] John: Well, in the Thriving Urology Practice Facebook group, last year, I guess two days ago, last year, someone posted, and he brought receipts. He literally said, this is how much I generated this year so far on the use of G2211. It's a good amount for a single urologist who appropriately used G2211. Most urologists are typically dealing with at least a single serious or complex problem for which there's an ongoing relationship with that patient, which is basically the definition of G2211. When G2211 came out a couple years ago, it was designed really to benefit the primary care docs, but there are other specialties for which the use of G2211 is appropriate, and urology is one of them. So whenever you're taking care of, say, BPH with urinary obstruction, or a cancer of some sort, I'd say single serious or complex problem, typically G2211 is appropriate. And there's no frequency limit regarding the use of G2211, meaning that if the patient sees you today for that problem and sees you again tomorrow for that problem, you can use G2211 on both visits.

I can lead a horse to water, but I can't make him drink. That is something that I've repeatedly said during presentations and lectures across the country and also in the Thriving Urology Practice Facebook group. Sometimes you have to just say, well, I'm going to help those who want to be helped. How's that?

Scott: Very true.

Budget neutrality and the death by a thousand cuts

Mark: I'll add two other points on all of this. Number one, remember that the way Medicare calculates the conversion factor is based on budget neutrality. So when we saw G2211 added to the code set, that was factored into the conversion factor. Any of your payer contracts that utilize a Medicare base are factoring in the use of G2211 to your overall payments, so it does amount to a piece of your overall reimbursement. If the payer's willing to give you a bump by the percentage of loss relative to G2211, then you can live with that. If not, then it's tough. That's the death-by-a-thousand-cuts side of the equation, and with your increasing costs around rent, utilities, staff and everything you have to purchase to run a medical practice, you have to factor all of this into your calculations. So ignoring G2211 is essentially giving the payers a pass.

[19:00] Scott: So when you're looking at UnitedHealthcare saying they won't pay for G2211, yet their contracts are based on Medicare, would you go back and argue that point with them individually?

Mark: Yeah. Everybody should try to argue every point with United when you're talking contracts. If you look at what your G2211 income is relative to your United patients and what your loss is, if you could get a percentage bump of even 0.2%, that's 0.2%.

John: And for a lot of practices, and this is another discussion in the Thriving Urology Practice Facebook group, about on-call payment to urologists, you have to be able to sometimes walk away from the table if your counterpart doesn't want to negotiate. I see that everywhere in the local practice environment, where hospitals and hospital systems are just saying, nope, your payment rules suck, to the payer, and we're not going to play in your sandbox. And really it's the same thing for the urologist being required to take call for free. That's a lot of liability, a lot of opportunity cost. You're mitigating a lot of risk for the hospital, you're assuming the risk, but you're not getting appropriately remunerated. Sometimes the only leverage you have, the ultimate leverage you have, is to just walk away from the table.

Now, that requires the understanding of how big of a pie that is in your overall total revenue. Can you sustain a hit where you drop a hundred percent of that particular payer? That requires a little bit of a deep analysis. I have never regretted dropping a payer, and my current payer mix is very, very small. It completely streamlines the practice. As most astute practices know, you have a patient calling in with insurance, you have to make sure the insurance is eligible, you have to figure out the copay, co-insurance, deductible. How easy is it for my staff to do that for a particular payer? For payers that are more problematic, there are a lot of hurdles, a lot of friction to get that information. Is it worth my staff's while? Is it worth my while to expend that staff energy and cost to the practice to continue to work with that payer? And if it is not, then have the payer come to the table: either make it easier for us or increase our remuneration so that we can afford to deal with this deliberately inefficient payer. So that's something to consider.

Mark: Yeah. And inefficiency takes many forms. How long does it take to pay? How much do you get paid? How much of a hassle do you have to get prior authorizations or referrals? All of that adds cost to your practice and your people and their time, which is a cost to you. So take a look at the big picture, not just the little picture.

John: All right. I know we're talking about seemingly nitty-gritty things, but inflation has gone up. The rate of inflation may be stabilized right now, but the actual inflation has gone up and will continue to go up. That's the way the U.S. system works. Yet our payment has not gone up year over year over the last couple of decades. So how is that ever sustainable for the urology practice? That is the question. That's why these minor details matter: understanding the way the Medicare system works, how there's budget neutrality and what that means for the urology practice. And when Medicare tells you that there should be a 0% change in your total payment based on Medicare's estimates for 2026, what does that actually mean? You have to really understand that so you can continue to thrive and survive.

Seminar reminder, sponsor and final thoughts

Scott: Very true. All right, well, let's wrap this episode up here. I want to remind you that the Urology Advanced Coding and Reimbursement Seminar is coming up in New Orleans on January 30th and 31st. We had a great seminar in Las Vegas in December, and we're expecting another great one in New Orleans. We encourage you all to join. If you go to prsnetwork.com, right there on the homepage there's a seminar registration button where you can get more information. Also, I 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. Okay, let's get some final thoughts on today's episode. John, final thoughts?

[24:00] John: Like many things in life, information is power, and those of you who know the information, and more importantly know how to apply this information, are going to win in this game of the third-party payer system in the practice of urology. I would highly encourage you to attend the Urology Advanced Coding and Reimbursement Seminar. I would highly encourage you to join the free Facebook group, the Thriving Urology Practice Facebook Group. The call issue, the G2211, the use of post-void residual within E/M, the modifier 25 issue, the UnitedHealthcare Medicare Advantage HMO plans requiring PCP prior auth, the new prostate biopsy codes in 2026: those are all discussed at UACRS and in the Facebook group. If you're not involved, if you're not attending, you're missing out on a lot of potential revenue that you deserve. So I encourage everyone to attend and stay educated.

Scott: All right, Mark, final thoughts?

Mark: John has well stated it. It is one of those things: I know every one of you is busy and doing a lot of clinical work and taking care of your patients. But you can't ignore the financial and administrative part of the business of urology. It's a piece that keeps your clinical engine running. It allows you to pay your employees, pay your bills, take vacations. All of those things make a difference. If you're not paying attention to that back-end financial, then you're going to have a hard time keeping your clinical support for your patients up and running. It is tough at this point in time, and it's not going to get much easier as we're going forward. So pay attention to your analytics. Don't be afraid to ask. Don't be afraid to change. Every year, change is forced upon you. If you don't adapt to that, you're going to have losses. It's a simple, unfortunate equation.

The other side of the coin that I'll add in this crazy world is that it does feel like you're in a weirdly powerless situation, but you're not. There are things we have in our favor as practicing urologists. In the practicing urology world, people have urologic problems, they need urologists, and we don't have enough urologists to take care of their problems. So you do have some leverage to make some decisions. Not all those choices are easy, nor are they easy to implement, but there are choices that can be made. There are a number of urologists that made them. John's one; he's now down to just a couple of contracts. Those are choices anyone can make. It's not like the demand isn't there. The laws of economics are strange in healthcare. They require different shifts, but they're still applicable to a certain degree. I won't say a hundred percent, because it's a little bit crazy with our third-party payer system and Medicare, but there are definitely areas where you can make a difference.

Scott: Very true. All right, that's all we have for today's episode. Thank you all for listening. Take us out, John.

John: Thank you for the privilege of your time. Happy coding.

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