Key takeaways from this episode

• 87798 is on the OIG's list for a spike in 2024 utilization and will stay a review target whether you bill 13 units or two. Most non-MolDX practices bill UTI PCR panels as individual 87798 probes up to the published MUE of 13, at $35.09 per unit.
• MolDX states still require a Z code before UTI PCR is payable, and the 2026 LCA updates did not change that. No Z code or MolDX code has been issued for any UTI PCR test yet, and the LCD still treats anything over five tests as a panel.
• An N35 remark on a PCR claim is a request for records, not a signal to rebill with fewer units. Appeal with the chart and a cover letter laying out the practice protocol for choosing PCR over culture and sensitivity, such as immunocompromised patients, elderly patients with recurrent UTIs, or symptomatic patients whose culture did not give usable results.
• The published MUEs are unchanged as of this quarter: 87798 at 13 and 87481 (Candida) at five. Reports from large labs that the MAC is internally limiting both codes to two units are unconfirmed, and the Group 5 LCA language about not paying above two is ambiguous as to whether it is per code or per panel.
• Do not drop from 13 units to two without a documented change in your medical necessity policy. Billing to match a rumored limit can be read as billing to get paid, undermines the necessity of the earlier 13-unit claims, and invites takebacks on claims already paid.
• Other panel codes such as vancomycin resistance and Staphylococcus aureus are still being paid in non-MolDX states. Denials are concentrated on 87798, with some activity on 87481.
• An ABN is worth getting but is not a guarantee. Transparency rules require telling the patient they may owe the full cost, and some denial types will not let you bill the patient even with an ABN on file.
• If the financial exposure is too high, slow down or refer out UTI PCR rather than change billing. Record requests are rising across Medicare and commercial payers, a urology group recently paid a significant fine for protocol failures, and the feedback loop on appeals will take time.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 284, recorded April 2026, with Scott Painter and Mark Painter of PRS Network.

Where UTI PCR stands: the OIG report, 87798 and MolDX

[00:05] Scott Painter: On this episode, UTI PCR increased scrutiny. Stay tuned. Welcome to episode 284 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter. Mark, we've got a lot going on in the UTI PCR world. A lot's happened, a lot's unknown, but do you want to bring everybody up to date on what's going on and where we are right now? By the way, today's date is April 10th, 2026, so it's changing as we speak. What do you have, Mark? It's crazy out there.

[00:51] Mark Painter: What we've deciphered to date is that the OIG report referring to utilization of codes in 2024 highlighted 87798 as a code that had significantly increased in use and was under review for inappropriate use. We all know that PCR has no real combined code, and most folks billing for PCR in non-MolDX states are using code 87798, which currently has an MUE published at 13. Most groups are ordering PCR panels that look for probably in excess of 20-some organisms and resistance tests, all done with individual probes qualifying for 87798.

Now, the MolDX states, which are half of the MACs out there, have indicated that they are not going to pay for UTI PCR testing unless there is a MolDX code, or Z code, which requires a clinical assessment and a technical assessment. That process has been very slow and difficult for folks to get through, and we haven't yet seen a Z code or MolDX code issued for any tests, although we hear there are a couple of groups out there that are close, which we're keeping an eye on. So that was already complex relative to PCR: half the country was able to do PCR testing using individual CPT codes with multiple units, and the other half essentially couldn't bill for UTI PCR testing.

Now there were some changes in the LCD recently for a number of states, trying to clarify their PCR policies. Those changes didn't change the LCD, but changed the LCAs, and that happened even in the MolDX states. I've gotten a number of calls from folks who are interpreting the LCA as allowing UTI PCR testing in limited circumstances. Let me be clear: in my interpretation of that LCA, I am not going to come out and say it has opened the door for UTI PCR without a Z code or a MolDX code. With that being said, there are some folks trying to use smaller PCR panels, because the LCD, which again did not change other than a couple of minor updates relative to specific CPT and ICD-10 codes over the last couple of years, does include the fact that a panel is anything over five tests. There may be some limited panel testing under five that would clearly fall under the LCD, but is that enough clinically to run a true UTI PCR test? There is some additional guidance relative to the number of units that could be used with any one code or two codes that some have interpreted as allowing at least a broader-than-five panel test for those MolDX states. I'm not sure that interpretation is as clear, and I'm not willing at this point to say that PCR testing in MolDX states is back up and open without a Z code. But we'll keep an eye on this issue and see if there are some smaller panel tests that may be ordered.

The N35 denials and the rumored MUE change

In the non-MolDX states, we are seeing a rash of denials, conveniently right around the time some of the LCAs were issued, although not every non-MolDX state issued an updated LCA for 2026. We are seeing an N35 come back for a lot of UTI PCR tests. The N35 is really a flag that says these codes are under program integrity or utilization review, which is essentially a request for documentation to support the full-panel UTI PCR test that was ordered. There have been a couple of large labs that have published that they had insider knowledge that the MUE being used for code 87798 is now two, and that they've changed 87481, which has an MUE of five, to a screen or internal MUE of two.

[07:21] Scott: Let me interrupt you for a second and read the descriptions for 87798 and 87481. 87798 is infectious agent detection by nucleic acid, DNA or RNA, not otherwise specified, amplified probe technique, each organism. And 87481 is infectious agent detection by nucleic acid, DNA or RNA, Candida species, amplified probe technique. I want to make sure we get those in.

[07:54] Mark: And that's each species, right?

[07:56] Scott: It just says Candida species, amplified probe technique. It does not say each, but it does say Candida species.

[08:04] Mark: Okay. And now that you're reminding me to define things, we should probably define MUE.

[08:11] Scott: Yes, medically unlikely edit, published, and we just checked these this quarter when they were released. For 87798 it's still an MUE of 13, and 87481 is an MUE of five.

[08:30] Mark: So we haven't seen any official changes from Medicare. Despite all the information out there, there may be real validity to it, but it may also be based on a conversation with one or two Medicare folks and a few test claims. What we're waiting for is clear published guidance, and the LCAs don't truly offer that. There is reference to a Group 5 code set, which includes 87481 and 87798, that indicates the payer will not pay above two. The issue I have with the way that is written is whether it is two from any codes, or two applied to any one code in a panel test. That's the clarification I'm really looking for. I can understand why people have interpreted it that way, and I'm not saying they're incorrect. But I am also saying that, as we all know, everything is subject to interpretation. And secondly, and importantly, just because you got paid doesn't mean you're going to keep your money. We are seeing a plethora of takebacks in the system these days, so a short-term win may be just that, a short-term win. In the end, with urology margins as tight as they are, we all need to play the long game.

What to do now: appeal on medical necessity, do not just drop units

So there are a couple of things I'd like to put out there that we do know. One: if you have already billed for these services with the appropriate number of units based on the panels you were ordering, there is a clause within the original LCD that Medicare will only pay what is reasonable and necessary, and with the MUEs, we know they're only going to pay for 13 units of 87798. I know a lot of panels out there test more than 13, and people could use more units, but we know it's not going to get paid. So those panels you order, knowing those rules, should be clear that you are ordering a standard PCR test, and have that defined within your office.

With that N35, it is not, in my opinion, the right move to bill it with lower units. The appropriate move is to appeal. You're going to need to get together your records, and a clear document as a cover letter that indicates your protocols and procedures as to why you are choosing UTI PCR over the standard of care of culture and sensitivity. That could be anything from an immunocompromised patient, to an elderly patient with routine UTIs, to a patient who is still symptomatic but nothing you've learned so far with a culture and sensitivity has provided the results you need. Those are really the key reasons. Some people also add that because of an additional test or the patient's overall condition, speed is of the essence. But again, that has to be clinically backed, and your documentation should support it. When you run those appeals, and we've talked to a lot of you before about this, make sure you have protocols in the practice that are clear: when you order UTI PCR, you have met these criteria. There is a selection process; it is not simply the way you do things. You've got to make sure it is appropriately selected, and this will be an ongoing process.

As far as moving forward is concerned, we have a lot of people thinking, well, we'll just follow the recommendation of the group to drop our units down to two. In those cases, I want to make sure we are not ignoring the published MUE, and those cases had better have the justification for ordering a lower-target test. It needs to be specific as to why you made those changes. I know you're going to get pressure, from the monetary perspective internally, but also from your suppliers, to make changes right away so you don't have to shut down your labs. But it is important to follow protocol and make sure you are doing things the right way. That means you are appealing based on medical necessity, your documentation supports those appeals, and you are following protocols established in the office, and your documentation, when you submit it to defend why you ordered those tests, is in order.

So my recommendation at this point is not to change what you're doing, but prepare to make a lot of appeals for those codes as they come in denied. Watch what happens with those denials. If you get official confirmation from the payer that the MUE has changed, then you can look at changing things. But you want to have written documentation or clear medical necessity for changing those orders.

[15:02] Scott: Mm-hmm.

[15:03] Mark: If you're worried about the financial impact, you might want to consider slowing down or referring out some of your UTI PCRs. That's another option. I think we're going to have to consider all of this. I know this isn't the best news for everybody, but it is important that you remain compliant, because this code, 87798, whether it's 13 units or two, is still in the OIG report and will still be a target for reviews now and in the future.

The other panel codes, the dollars at stake, and ABNs

[15:42] Scott: So Mark, what about the other codes associated with PCR testing? I know there are a number of CPT codes that can be billed, and this is specifically targeting 87798, but are the other codes still getting paid?

[15:58] Mark: In the non-MolDX states, we are seeing the other codes getting paid, but the denials are coming through specifically on 87798.

[16:09] Scott: And by the other codes, we mean things like vancomycin resistance, Staphylococcus aureus, and those PCR codes that are often included in a PCR panel.

[16:22] Mark: Yes. The only other one we're seeing a little activity on is 87481, the Candida. That's probably why the reaction from some of these groups is to use two instead of five. We're watching it evolve. All of the denials are still centering around the N35. It may be that they're taking an extra look at 87481 and whether that MUE should be five. They may have some internal changes, but again, we want to see that in writing relative to what you're going to do moving forward. This is something we'll keep an eye on, and we'll keep you posted. And I'm going to remind you again: getting paid now is not necessarily getting paid for all time.

[17:24] Scott: And we will let you know that each one of these CPT codes, each time you bill it, the fee is $35.09. So if you're running thousands of these a month, moving that down from 13 units to two is significant. That is obviously something to be aware of. Also, the information you get when you're doing these appeals and trying to figure out what's working and what's not takes time to come back. As Mark said in the moving-forward part of his discussion, you need to consider all of that as we're learning what's happening. The feedback loop is only as fast as we can get claims paid and appeals resolved. Keep that in mind as well. One other question for you, Mark. Can you protect yourself with an ABN, or a cash-pay option with your patients?

[18:43] Mark: That is a good question. The ABN is probably not a bad idea in these situations. We could see a medically unnecessary service denial, which may block some actions and activities moving forward, so the ABN is a good option to potentially protect that. But with the transparency laws, you also want to make the patient aware that if they've got an ABN, they might have full responsibility for the cost. So you've got a couple of different laws to navigate. And some of those denials, depending on how they come back, may not allow you to bill the patient for the differential, even with an ABN. It depends on the denial and where that is. An ABN is not a guaranteed insurance policy, but it is at least an additional step that could be taken to protect the financial downside.

Why dropping from 13 units to two without a policy change is dangerous

[19:55] Scott: Just to restate your position: what you're saying is you like to see the published rules and regs from payers and their interpretation, as opposed to going on other people's empirical data on what's happening, until you can verify that. Is that what you're saying as far as dropping down to two before anything is published?

[20:35] Mark: Yeah. There are a couple of different things in there. One, and I think where you're going is the right issue: unless we have a published MUE that lets us know the maximum number of tests they will pay for, that they consider reasonable and necessary, then the tests you order should reflect what you actually need, with the MUE considered part of a payment agreement, if you will. The secondary piece is that when you're changing all of a sudden from 13 to two without a clear change in your medical necessity policy, that is essentially billing in order to get paid, which could be interpreted as fraudulent activity or abuse of the system. I don't know which way they would classify it. It also undermines the medical necessity of why you ordered 13 in the beginning, and it could lead the carrier to go back and look at the 13s that were billed before and say, why did you overcharge me for all of those? It could open the door to go back and take those other tests away. There are a lot of different things in play that I'm very concerned about, and that's the reason I'm recommending that unless you're going to change how you do the test, how you order the test and what you're testing for, I would not change the way I am billing going forward.

I also want to make it clear that I'm not saying, nor should anybody tell you, that the appropriate number of organisms to screen for or test for is set in stone. If you feel that a lower number of organisms should be tested for and that gives you the information you need, it is relevant to set up a lower number of organism identification tests. It just depends on how you can support that change in the medical necessity. I'm not saying it can't be done. I'm saying it needs to be done with medical necessity.

[23:25] Scott: I think that's a very good point. When you look at the MUEs, you often try to hit that 13, but really it's about the medical necessity, what you're testing for and what your medical decision making is. It's a great point. All right. I know there are a lot of unknowns here, and we'll keep you posted as we move forward, but 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. Any final words of wisdom today, Mark?

Final thoughts: documentation, protocols and the enforcement climate

[24:19] Mark: Again, what you order and how you order it matters. It also really matters that you have appropriate protocols and procedures for selecting when you use any test that's in the market, and it had better be well documented. As you all know, the number of medical record requests is going up significantly in Medicare and with other payers. Some come through as N35 denials; some come not as denials but as straight medical record requests before processing. Your records are being reviewed routinely at this point, and you really do need medical necessity in every case. Remember that the federal government right now is under a strong push to save money, and a piece of that is focused on fraud and abuse. We've all seen by now that a urology group paid a significant fine for not changing its ways or following protocol relative to PAE, and there were a few other things in there. My bet, and I did not look at their records and was not involved in that case at all, is that there were some administrative errors relative to not having all the information in the medical record or not submitting it appropriately, which is what we've seen before. It's about the documentation. It really is. It's about your protocols, and in the end, we all know, and we've emphasized this over time, that everything you do has to be for a medically necessary reason. That documentation, your protocols and procedures, all of that needs to be in the medical record so you can provide that information to any payer easily. Support why you did what you did.

[26:30] Scott: All right. I'll also remind you that the PRS Coding and Reimbursement Hub is up and running. You can go to prsnetwork.com/urologyhub for coding and reimbursement information for different categories, kidney stones, prostate biopsies and a number more, and we're adding more every week, as well as specific products. Right now we have a lot of discussion on prostate needle biopsies, so you can go there and check out the various products for prostate needle biopsies. It's all there by product as well as by category. We encourage you to check that out. That's all we have for today. Thank you all for listening. Take us out, Mark.

[27:31] Mark: Happy coding.

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