Key takeaways from this episode

• Medicare telehealth flexibilities are extended through the end of 2027. The continuing resolution that ended the government shutdown keeps telehealth on the standard E/M codes with the telehealth modifier, paid at parity with in-office visits, with the same documentation rules as today.
• Audio-only telehealth is allowed only as a second choice. The patient must first be offered an audio-visual visit; if the patient agrees to audio-only and the physician believes it is medically appropriate, the visit can proceed.
• The new telehealth CPT codes 98000 to 98015 carry lower RVUs, and Medicare chose not to adopt them. Expect telehealth payment to drop whenever those codes are eventually adopted, so build the telehealth business line now while E/M parity holds.
• Run telehealth as a scheduled block of established-patient follow-ups, prepped like an in-person visit. Dr. Lin schedules telehealth at the end of morning and afternoon sessions, has the MA contact the patient and prep the chart the same day, and reports near-zero no-shows and visits that run on time or early.
• Expect Medicare to add guardrails to permanent virtual direct supervision. No Internet-Only Manual update has appeared yet, but Medicare has signaled it was never intended to allow supervising from the golf course, and a requirement that the physician be virtually connected to the office during visits, not merely available, may be coming.
• 51720 (bladder instillation of an anticarcinogenic agent) can be billed with 52235 (TURBT, medium tumor) only if the instillation is done as a distinct, separately documented step. NCCI marks 51720 as unbundling allowed with a modifier, unlike catheter codes 51700 to 51703, which are never unbundled; instilling mitomycin or gemcitabine in the OR is effectively an NCCI block, while instilling in the PACU with a catheter placed in the OR supports modifier XE for Medicare (or 59 for some private payers), with the same diagnosis code likely to trigger record review.
• Billing multiple level-five visits by time can produce a "medically impossible day" and lead to Medicare exclusion or fraud allegations. Time-based 99215 requires 40 minutes or more (60 minutes for a new-patient level five), so 35 time-based level fives in one day is indefensible after the fact; sampling audits will not catch it, whistleblowers do.
• Coding by time is usually a financial mistake as well as a compliance risk. A time-based 99215 pays a national average of about $193 for 40-plus minutes, while four medically necessary 99214 visits at about $160 each fit in the same hour, so let medical decision making and medical necessity drive the level.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 275, recorded February 2026, with Scott Painter and Mark Painter of PRS Network, and guest Dr. John Lin.

Welcome and the Thriving Urology Practice Facebook group

[00:00] Scott Painter: On this episode: keep calm and telehealth on, you have to instill it where to get paid, and what is a medically impossible day? Stay tuned. Welcome to episode 275 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, and we want to welcome back special guest Dr. John Lin. Dr. Lin is a solo practitioner in Gilbert, Arizona, and the founder of the Thriving Urology Practice Facebook group. John, for those who aren't members of the group, would you share how they can join and what it is?

[01:00] Dr. John Lin: For a lot of urologists, APPs, residents, practice managers, coders and billers, some of them will tell me the only reason they're on Facebook is so they can access the information in this group. It is a free group and it is so easy to join. You just look up the Thriving Urology Practice Facebook group, click join, and answer some very basic questions. We do limit membership to US-based urology practice people, so there are no vendors. Anything you put on social media is for public consumption, but it is a private group, so there is some privacy, and I do allow people to post anonymously. So you get to post things and ask questions that you would otherwise feel a little uncomfortable asking in person, or if you weren't anonymous. It's a great source of information, a great source of updated information, like some of the things we're going to talk about today. Back to you.

Telehealth extended through the end of 2027

[02:00] Scott: Great resource. Join today if you haven't. Let's get started. The first thing we want to talk about is telehealth. Mark, what do you have for us?

[03:00] Mark Painter: As expected, we did see the government shutdown end, and pretty quickly this time. It took a couple of days, and it was interesting: after something passed the Senate 71 to 29, it went through the House and passed by one vote, with 21 Republicans crossing the line and voting against the bill and 21 Democrats jumping to the other side and voting for it. So it was definitely a squeaker, and a lot of it actually had nothing to do with healthcare funding. It had everything to do with other political issues, specifically DHS and the immigration issues surrounding the deaths in Minnesota. They carved that out and passed the bill.

For telehealth, it extends the current COVID telehealth rules through the end of 2027, so we got a two-year reprieve where we don't have to worry about telehealth. There were some other fixes and other things in that bill that we won't dive into, but hospital and rural healthcare did get some extra funding, and Congress took a couple of extra steps to designate where the healthcare dollars are supposed to go. There were a couple of interesting things in there as well, but the main thing we were focused on was telehealth, and that did get extended until the end of 2027. So we're solid within Medicare, as we knew we were going in. Why do they have to keep throwing it into the continuing resolution and tying it to the funding, when they have six bills that could make it all permanent and leave it outside of these crazy negotiations? For some reason they can't do it. But here it is, and we're good all the way through 2027.

The way it's extended, it keeps it on the E/M codes with the modifier, as we're doing right now, which levels out payments for telehealth with the office. We still have our standard rule set that we have today: audio-only has to be second choice. Essentially the patient needs to agree to it, but first they need to be offered audio-visual. That's the lean CMS really has, that audio-visual is much closer to, and therefore more representative of, an in-person visit. Of course, they didn't want to block telehealth for people who could not get video, so they added that if the patient agrees to audio-only and the physician believes it is medically appropriate, we're all good to go. Documentation rules stay the same. You can keep treating telehealth as a visit and use it as you need to and as is medically necessary, moving forward from the legislative side and from Medicare.

Scott: John, comments, thoughts?

[06:00] John: Hence, I'd like to say keep calm and telehealth on. We've been granted this amazing opportunity since the horrible thing with the pandemic, and that is the acceleration of the use of telemedicine. The entire US loves it. I know my patients love it. And as of now, telehealth still remunerates the same as if the patient is seen in person, meaning you are still using the typical evaluation and management codes, and when you use these codes you're paid the same for seeing the patient in real life as for seeing the patient via telehealth. Now, I will guarantee you that in the future this is going to change, as we already have some new codes, I think 17 new codes, 98000 to 98015, so 16 new codes for telehealth. Whenever those codes are adopted, the RVUs are going to be lower than how we're being remunerated right now. As with anything CMS does, it seems like the early bird gets the worm. If you adopt things early, you understand the rules and you can utilize them to your advantage, and then your life is easier, until it's not.

New telehealth CPT codes and making telehealth a business line

[07:00] Mark: So true. And it is interesting with the new CPT codes that were out there. This was a softball served up by the AMA. There was a contingent within the AMA that really wanted to separate the telehealth codes from the E/M codes, and when they came through and got valued, the valuation obviously took out some of the overhead relative to a telehealth visit that is not the same as what's happening in the office as far as paper and gowns and those types of things. Medicare decided not to mess with it, so we thank Medicare for this one. And John, you're right, the early bird almost always gets the worm, and a piece of it is risk and reward. The folks who have to plow the road for all the coverage issues and take some of the risk do get paid a little better, as we look at unlisted codes and Category III codes and all of those things. So this is good news as far as I'm concerned, and as we've been talking about for a while, it's time to stop treating telehealth as an optional hole-filling tool and move it into a true business line within the urology office.

[09:00] John: Before the pandemic, Mark, I remember you hounding us: "You've got to do this, you've got to do this." And then the pandemic fully accelerated the adoption of telemedicine and telehealth, and that was the case for me too. Interestingly, in January, right around the time of the Urology Advanced Coding and Reimbursement Seminar, you were again talking about telehealth: "You should consider doing it." Then in March I started heavily looking into it, and then April, May 2020, we all know what happened. So the timing couldn't have been more perfect for me, and since then I've never stopped using telemedicine. Some of the things you suggested during the seminars, like chunking the telemedicine visits: the way I do it is at the end of the morning session of seeing patients in person in the office, and at the end of the afternoon session, that's where all the telemedicine visits live. We prep the chart with the MA the same way we do when the patient is being seen in person. So we treat it like a true in-person visit, except the only difference is it's being done virtually and not physically in person.

[10:00] Mark: John, do you have any issues with no-shows for telehealth visits? Just out of curiosity.

[11:00] John: That's a great question. The way we prepare things is that the patient will be on the schedule from a previously scheduled in-person visit. I see telemedicine best utilized for follow-ups, when I already know the patient. We've already met in person, the examination's been done, et cetera. Then on follow-up: how did the medication work, what did the pathology results show, did you have any side effects, how did the surgery go afterwards? Those where I don't have to check the wound by touching the wound are best for telemedicine. In person is a little less predictable as far as how long it goes. So after I've established that relationship, the patient is scheduled for telehealth, and on the day of the appointment my MA preps the chart as if we're seeing the person in the office. The cancellation rate is extremely low, because she's already contacted the person the day of the telemedicine appointment and updated the chart, and at the time of the appointment the patient usually logs on five minutes early. Here's the good thing: not only do they almost always show up, the appointments are always running on time. The problem I end up with is that when they run on time, or sometimes early, I have to contact the next patient by texting them and saying, "I'm ready to go if you can jump on early." So often my telemedicine afternoons or morning sessions end before the scheduled time.

[12:00] Scott: That is true. I hadn't given it that much consideration, but having had telehealth visits myself, it's easy. Wherever you are, you can take a telehealth visit with your phone. So that makes sense.

Change management, family participation and remote care

[13:00] John: I think Mark has talked about this during the seminars forever: you should set it up as the typical thing you do. During the most recent Urology Coding and Reimbursement Seminar in New Orleans just a few days ago, a lot of the sideline conversations, not during the presentations but between them when people talk to Mark and Scott, were some of the most robust and interesting conversations. A lot of the conversations I had this past weekend were really about change management. If the doctors, the APPs and the staff in the office are comfortable recommending telemedicine, it becomes the norm. If the staff is comfortable talking about the use of nitrous oxide, or mail-in post-vasectomy semen analysis, it becomes the norm. If the doctor's not comfortable talking about or utilizing a particular procedure or line of service, the patients will feel the discomfort and the resistance. I think that is the biggest hurdle for a lot of practices. Everybody needs to be on board. Everybody needs to be comfortable talking about telemedicine. This is not the future; it's today. It's the norm today in a lot of practices, and it's good for the patient and good for the practice.

Scott: I bet Dr. Lisa Finkelstein is very proud of where telehealth is today. She helped pioneer this.

[14:00] Mark: It was an essential tool in rural areas way before everybody else started to leverage it. Ultimately, as I've seen telehealth incorporated into practices, where we have effective change management to drive it in as a real visit, a real opportunity to see your patients where they are, meet their needs and continue to provide great care, it's one of those areas where there is so much time savings and resource savings for both the physician and the patient. It opens up your schedule to see more patients, and it is that change management tool of working it into the workflow that makes it so efficient and helps urologists fill the need of getting patients in faster, seeing more patients, making sure they're where they should be in their treatment path. You can flag them to come in if they need to. You can check in with them. There's a lot to it. And we're going to see the growth of remote diagnostic tools and everything that comes with the potential of treating patients remotely, to provide services to people who maybe wouldn't come in and wouldn't get it. So it's also an opportunity to visit with patients who normally wouldn't come into the office. We need to think of it as a way to connect with our patients that furthers care and furthers the development of the relationship, so you can create that trust and that bond that sometimes feels like it's going south with everybody moving as fast as they are right now.

[16:00] John: One unintended, or unexpected, benefit is that households and families are typically spread apart across the United States. The patient may be, or should be, in the state in which you have a license when you do telemedicine, but the siblings or the kids of the patient may not be in the same state. Now with telemedicine, you can have people from disparate parts of the country join the same telemedicine session to go over that pathology report, to go over that cancer discussion, so you do it once, everybody hears the message, and everybody has the ability to ask questions. The patients benefit, you build great rapport with the family members, and ultimately it's better care and actually less medical-legal liability, because often the lawsuits come not from the patient but from the family members of the patient, or the patient encouraged by the family members. So that's another benefit.

Scott: All right. Keep calm and telehealth on. Let's move on to our next topic.

Virtual direct supervision: guardrails may be coming

[17:00] Mark: I want to jump into a related topic that we didn't talk about ahead of time, but it popped back into my head. I've been having some recent conversations with folks regarding virtual direct supervision. As we know, that was extended permanently, and we've had different discussions with folks around the country. It does look like, although I haven't seen any updates yet to the Internet-Only Manual, the folks at Medicare are probably going to be adding some parameters around when virtual supervision is allowed. There was one comment from somebody who actually talked to Medicare that basically said this is not intended to allow the physician to play golf and supervise their staff from the golf course. So I think we are going to see some additional instructions. We knew it was going to come, but it sounds like it's going to come in the near term, now that everybody's back at work at the federal government. We're going to have to keep an eye on those things. There may be a requirement that the physician is virtually connected to the office when visits occur, not just immediately available. We'll keep you updated as we see information released, but I did want to warn everybody that I'm starting to see the rumblings of Medicare putting parameters around virtual supervision.

John: The ability to use telehealth for direct supervision, for somebody else doing the work that requires direct supervision, is too good to be true to last forever. Well, now it's the rule.

Mark: It is the rule, and they did make it permanent, but it's too good to allow it to just be the Wild West. So we'll start to see those guardrails come in, and it'll probably be fairly soon. We'll update you on those as we start seeing more.

Instillation with TURBT: billing 51720 with 52235

[19:00] Scott: All right. Now let's move on to the second topic. John, do you want to read the question that came in and inspired this segment?

John: Yes. You have to instill it where. This question came from Kimberly in the Thriving Urology Practice Facebook group, and it goes like this: "I have a question. Are 52235 and 51720 allowed to be charged together, since 51720 would need a 59 modifier? I thought it was not allowed because it was the same site/organ. We have an auditing company saying it is allowed. What are your thoughts? Thank you."

[20:00] Mark: So 52235 is our TUR of a medium bladder tumor. When you look through the bundling edits, 51700, 51701, 51702 and 51703 are all bundled and marked as unbundling never allowed. That's something we see quite frequently, as catheters are typically left after procedures performed through the urethra. That's essentially where those bundles are, and of course most of the catheterization codes have a separate procedure designation as well. But 51720 is marked as unbundling allowed with a modifier, and ultimately the instillation effort is a little more than the standard leave-behind. I think that's why they put 51720 as unbundling allowed with a modifier. But you do need to make sure that effort is clearly documented.

We do have some issues where folks instill not right at the procedure time, but maybe in the recovery room. Technically it is allowed as a separate procedure because of that extra effort and because of the instillation of the drug, which is not typically, but oftentimes, part of the procedure. The documentation needs to be clearly separated as a distinct procedure, that that work was done. And I will tell you that in most cases you're going to have the same diagnosis code, so it is going to see some documentation review in order to get paid, and it is going to fall under multiple procedure guidelines. But the pathway is there for 51720 to be billed with a separate modifier. To make it easier, this might be one where you consider the XE modifier, which is the separate encounter. Essentially, you do the procedure in the procedure room, and then if you instill in the recovery room, you could count that as a separate encounter with the patient and use the XE, which might make it a little easier to get paid.

[23:00] John: Just for clarification, 52235 is TURBT of a medium-sized tumor, and 51720 is bladder instillation of an anticarcinogenic agent, including retention time. Typically, the patient comes in with a bladder tumor and you schedule the patient for a TURBT and immediate postoperative intravesical chemotherapy. Doing both the TURBT and putting in, for instance, mitomycin or gemcitabine while the patient is in the operating room is probably going to be impossible to get paid, because this is an NCCI block right now. If you do the TURBT in the operating room, the patient goes to the post-anesthesia care unit, or recovery room, with a catheter already in place that you put in in the OR, and you put in the gemcitabine or mitomycin C in the PACU, then you can bill the two together on the same day, possibly using a 59 if it's a private payer, or using XE for Medicare and some private payers. If you do that, you get paid for both. Of course, the documentation has to be separate. You would document that you did the TURBT and put in the catheter in the OR, and you would document the fact that you instilled the chemotherapy in the recovery room. That's the kosher way to do it.

Scott: Makes sense.

What is a medically impossible day

Scott: Okay, let's move on to our final topic: what is a medically impossible day?

[25:00] John: There's no shortage of scenarios brought on by the attendees of the Urology Advanced Coding and Reimbursement Seminar. One of the best things about these seminars is the participation. This past weekend I presented on the use of modifiers, especially modifier 25, and we were going on about how you should do this to optimize the visits, this is when you can and cannot use modifier 25. Then we talked about evaluation and management and presented scenarios, and I recall, as I was on stage, one attendee raised her hand and you could see the frustration and anger as she asked this question: "I have a provider who sees about 50 patients a day, and about 70 percent of his patients are level fives, and he is billing based on time." Just to give you some context, billing based on time for a level five requires either 60 minutes or 45 minutes per patient, depending on whether it's a new or established patient. So if you're seeing 35 patients at level five billing based on time, I don't know what kind of time machine that doctor has to have 35 hours in a day, but that is not possible. I cautioned her that this is what's called a medically impossible day. Your doc's going to be in trouble, so educate the doc.

[26:00] Mark: That's a ticket to a suit change.

John: Join the chain gang.

Mark: An address change could be in the future for that. That's definitely one where we've seen folks excluded from Medicare, and further action taken, for folks who have clearly billed for overlapping time, or have basically been accused of committing fraud because it was a medically impossible day. Too many hours, not enough real hours.

Scott: Have you seen that in any of the audits you've done, Mark?

[27:00] Mark: Typically when we do audits, we do sampling audits, so we wouldn't pick it up, because we wouldn't see a full day. Do we see people using time? Yes. Do we see time used appropriately, based on the notes? Yes, we do, and there are times when that happens. Do we sometimes see patterns on level five that look a little suspicious? Yes, and we flag that for the offices to take a look at. But the deep dives, those are whistleblower things. Those are cases where it's really hard to defend. In fact, it's impossible to defend those. Those are the ones where we say, sorry, we can't help with that. It's correctable ahead of time, but afterwards it's very difficult to walk back from.

[28:00] John: As I mentioned during the presentation, fashion trends may change, but I don't look good in orange. It's impossible to defend these types of claims. First of all, it's very difficult for the typical urology outpatient practice to bill multiple level fives on one day. The question is, what is the medical necessity to spend so much time talking about a particular topic across multiple patients on the same day? Even if you can spend 45 minutes with these patients, you have to have a good reason. Talking about golf, talking about fishing, talking about the cars you're building with the patient doesn't count. You have to spend the time talking about the care of the patient, not some hobby you're both interested in.

[29:00] Mark: So true. You could also add that the national average for a 99215, which is 40 minutes or more, is $193. That is not the typical hourly rate a physician would want to see, when you can look at a 99214 at $160 and provide four of those in an hour, or more, based on actual medical necessity and not using time. That's always been one of those issues: time is easy when you're looking at all the E/M guidelines, and maybe a shortcut so you don't have to really learn medical decision making. But boy, it is definitely a financial mistake to live off of time. It's one of those tools that should be used only when appropriate, and ultimately medical necessity, as John mentioned, should be the driver of all your visits.

John: In life, as in medicine and billing, anything based on time is typically inefficient. Exchanging time for money is not the most efficient way to be productive.

Sponsor, final thoughts and the PRS Hub

[30:00] Scott: So true. Okay, let's wrap this episode up. 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. Let's get some final thoughts, and we're going to start with John.

[31:00] John: I'll try to keep it short. Just because you can doesn't mean you should. When it comes to coding and billing, understanding the rules is supremely important. I would encourage everyone to start planning for next year's Urology Advanced Coding and Reimbursement Seminar. And for those of you who are not subscribers to AUACodingToday.com, the question about the bladder instillation and TURBT, whether or not you can use them together, is answered by a feature of AUA Coding Today called the bundling matrix. You can throw your soup kitchen of codes into the bundling matrix and it will tell you which codes can and cannot be billed together, which modifiers you can use, which code should be listed first and which second, in the appropriate non-facility or facility setting. The bottom line is, the more you know, the better you are going to fare in this healthcare game. Back to you.

Scott: All right, Mark, final thoughts.

[32:00] Mark: One, going back to the beginning: telehealth. It's time, actually past time, to really adopt telehealth and do it the right way. Identify the visits that make the most sense for telehealth, take control of it, and leverage that tool. It's here and it's going to stay. That's number one. Number two, understanding the rules top to bottom is ultimately a requirement in today's healthcare game. This system is set up wrong in so many ways, and unfortunately it is the one we function under. As we've talked about for years and years, it's documentation, it's understanding, it's leveraging all of this. And now that we have artificial intelligence and some of those tools behind us, I think a lot of folks are thinking, "Now somebody will make decisions for me." Actually, you still have to be the interaction between the visit and the computer, and missing that knowledge is going to cost you even more in the AI world, because the computer is not going to care. It's going to flag it based on what is actually put in the record. So you need to continue to understand these things. And of course, as is the rule in all of what we've done over the years, and the reason we keep doing seminars year over year: typically the questions don't change a lot, but the answers do. That's what we're going to see with potentially virtual supervision and all the other stuff that's out there. We've got to stay on top of these things and make tweaks. It's an ever-changing, ever-evolving chess match, and we have to understand both sides and their motivations to make sure you can continue to have a healthy financial practice, so that you can provide the clinical services your patients need.

[34:00] Scott: I will also let you know that the PRS Coding and Reimbursement Hub is live and got a fresh update this year, so you can check that out at prsnetwork.com/urologyhub. Also, right there on the homepage you can see a little button, so if you just go to prsnetwork.com, click on the Hub and check it out. There's a lot of great information on categories like kidney stones and prostate biopsies, as well as individual products and devices, our pharmaceuticals and devices. We are building that out and continually adding to it. It's a great reference, so you don't have to click around the device manufacturers' websites or the pharmaceutical manufacturers' websites. Go there, one-stop shop. We have a bunch of our PRS CodeMatrix guides out there. I actually talked with one attendee at the seminar, and she said, "Are you guys updating the guide? I want to have this not only for me as a quick reference, but also as a backup if I'm not there." These quick reference guides, the CodeMatrix guides, are something you can print out or keep in a folder on your computer and access when you're billing those particular products. We also have calculators on there so you can check whether a device is financially feasible for your practice. So there's a lot of stuff on there, and it's going to get better and better. I encourage you to check it out. That's all we have for today. Thank you all for listening. Take us out, John.

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