Key takeaways from this episode

• Cystoscopic stent removal with replacement is billed as 52332 alone; removal only is 52310. Medicare bundles the removal into the replacement, so 52310 and 52332 are never billed together for the same encounter.
• Pulling a stent by an externalized string has no CPT code and is part of the office visit. Only when the string is cut and left in the bladder does the cystoscopic removal (52310) or removal and replacement (52332) apply.
• 50385 and the related fluoroscopic exchange codes are for stent exchange without cystoscopy, with the snare passed beside or through the stent from above. As listener Dr. Chapman noted, that is rare in urology; the codes are not for a routine cystoscopic exchange.
• RAC auditors have begun requesting records on PAE claims that report both 37242 and 37243. 37243 (organ embolization) is the standard PAE code; 37242 (a specific arterial branch) is only supportable when the note clearly documents treatment of an additional feeding artery beyond the prostatic arteries, and the RAC may also look at 37242 billed alone with a BPH diagnosis.
• Expect prepayment record requests on the arteriograms and selective catheterizations billed with PAE. Document each vessel and code case by case rather than relying on a billing pattern; audit your existing PAE records now for completeness.
• Bill 55715 for every additional prostate lesion targeted despite Medicare's MUE of one, and appeal the automatic denial with the MRI and procedure documentation. The MAI of three means the claim will be denied or sent for record review, so the note must clearly identify each region of interest on the prior MRI and each lesion biopsied; do not split units onto multiple lines and do not cut back to one unit.
• 55715 is an add-on to the MRI fusion and MRI-guided biopsy codes only, regardless of approach. It cannot be reported with the ultrasound-only codes 55707 and 55709, and it pays about $47.10 in the facility setting, making the appeal a matter of principle as much as money.
• Payer scrutiny is increasing through downcoding, record requests and fraud-and-abuse initiatives, catching the 95 to 98 percent who code correctly. Retrain clinical and administrative staff, monitor and double-check documentation, and keep appeal protocols ready.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 290, recorded May 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Clarifying stent removal and exchange coding

[00:00] Scott Painter: On this episode: stent removal code clarification, PAE RAC audits, and 55715 prostate biopsy additional lesion medically unlikely edits. Stay tuned. Welcome to episode 290 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. First of all, we wanted to talk about episode 287, where we discussed a question about stent removals. We had an email come in from Dr. Chapman, which we really appreciate. It sounds like there was some confusion on the podcast over our clarification and what was said. Dr. Chapman wanted to let us know that he's a listener, which we really appreciate, and he said he felt we didn't clearly explain that 50385 is done without cystoscopy, that we only explained it is for an internal stent exchange done through the urethra and must include the use of fluoroscopy. He writes: "These are all qualifiers for how any urologist would typically exchange a ureteral stent, cystoscopically, unless done in the office without fluoroscopy. But at no point did I hear you say that it's specifically not allowed to be billed if cystoscopy is done during the stent exchange. In my opinion, CPT code 50385 has no use in the urology field, and discussing it only creates confusion. It really seems meant for the very rare circumstance when an interventional radiologist, or perhaps a urologist I've never met, might change a ureteral stent under fluoroscopy alone. I've never seen this done by either an IR doc or a urologist." Okay, Mark, do you want to respond?

[02:00] Mark Painter: Yeah. Sometimes when we get into the coding weeds, we end up in the weeds, and we did in this particular question. The question from Ben Carantarat really did seem to be focused on stent exchanges provided with snares under fluoroscopy, which we have seen done very infrequently, as Dr. Chapman indicated. Typically we see this with an encrusted stent, or a stent that has been in for a while and is not easy to remove using standard cystoscopy or a string. We should have expanded that conversation to include all potential stent removals, so we'll do that today.

The majority of stents we see removed, or removed and replaced, by urologists are performed with a cystoscope, because the urologist doesn't want to leave the string outside the body. That doesn't mean it can't be done. We have plenty of urologists who, when they place a stent, leave the string outside the body, and then the patient comes in and the string is simply pulled to remove the stent. That doesn't have a specific CPT code and is usually included as part of a standard office visit.

When the string is cut and left inside the bladder, as a lot of urologists do, we have two codes: 52310 for the simple removal of the stent without replacement, and 52332, which we should definitely have mentioned in that code discussion, because the majority of urologists use a cystoscope to go into the bladder, identify the string, remove the stent, and then use the cystoscope to replace the stent. That is the most common method, and of course Medicare has bundled the removal with the replacement. So we can't bill 52310 and 52332 together. We can only bill 52332 for the insertion if we do both a removal and an insertion. If it's just the removal, it's 52310.

The 503 codes we discussed, and the 506 code from Ben Carantarat's question, are typically used, as we mentioned in the podcast, with fluoroscopy to remove and replace the stent without a cystoscope, and importantly, those codes are used when the snare is pushed in beside or through the ureteral stent to snare from the top, not a simple snare used to find the string within the bladder. That was one of the controversial issues, and that's what we were trying to focus on in that answer. So we definitely appreciate the note letting us know we weren't as clear as we should have been, and we'll expand the discussion beyond just the question to the overall coding for stent removal. We'll endeavor to get back to broadening our discussions and thinking outside the box, not just about the question.

[06:20] Scott: Great. Comments, questions?

[06:22] Dr. Ray Painter: No comment. Good explanation.

[06:28] Mark: Isn't that technically a comment? And thank you.

RAC audits targeting PAE claims

[06:32] Scott: All right, let's move on to the second thing. Hot off the press, we understand there are some new RAC audits coming in for PAE. What do you have there?

[06:44] Mark: There haven't been a lot of these RAC audits, but we just heard from one of our industry partners that a few practices had received them. The RACs are the recovery audit contractors. They're given the opportunity to analyze claims data for the various MACs, and if they see coding anomalies they can officially request record reviews. If they discover that the MAC paid the claim inappropriately, either higher or lower, the entity performing the RAC audit that identified the issue and did the first-level review gets a percentage of the recovery. So they're bounty hunters. They've been focused on big-ticket items for a number of years, which makes sense based on the recovery percentage.

Specifically, the RAC audits to this point are targeting claims in which both 37242 and 37243 were reported. To give you a little background, 37243 is the most common code we see used for prostate arterial embolization, or PAE. That code is specifically for an organ treatment, and that's why 37243 makes sense. 37242 is more specific to a particular arterial branch, and there was some confusion early on when PAE was first getting started, when a number of folks, based on their interpretation of the codes, felt 37242 was the correct code and billed it bilaterally. But as the rules and interpretations came in, it was determined that 37243 was the more appropriate code for treatment of the prostate using arterial embolization.

Now, there are cases we've seen where both codes may have been used, and may have been used appropriately: essentially, when you've got a native artery with some additional feeding of areas within and around the prostate or within the pelvic area. That's what they're looking for. Whether their interpretation will allow 37242 in addition to a standard prostate arterial embolization, whether it's two arteries blocked, which is typical in the bilateral treatment of BPH, or an individual with an additional artery feeding through, we'll see. Some of the operative notes we read were addressing additional feeds that treated more than just the prostate area, focused on the entire pelvic area and the potential of feeding the prostate from a different set of arteries. Ultimately, if you performed a service reported with 37242 and 37243, you need to make sure your documentation is in place and very clearly explains it.

We have a feeling they might also take a look at 37242 when the diagnosis was BPH, even if 37243 wasn't billed in those cases. But we'll see what the RAC auditors do. It seems to have started with 37242 and 37243 as a combination. In the spirit of everything else we just talked about, the other thing I'll mention about PAE billing, and those of you providing PAE services know this, is that it is not uncommon to see a request for medical records prior to payment focused on the arteriograms and the selective catheterization performed with some PAE. That's another area where hopefully everyone is documenting clearly. This fits into everything we always talk about: documenting and coding in tandem. Pattern billing is something you use as a guide, but reality is case by case, and the documentation needs to support every code for the chart reviews coming prior to payment, as well as the situations where the RAC might take a second look. We'll keep you posted as we see results around the country. But it is a point in time where you might want to take a look at your records and make sure they are accurate and complete, supporting all the services you bill.

[13:19] Scott: Ray, comments?

[13:21] Ray: Nothing to add.

[13:24] Mark: We're all learning as we go, right?

The 55715 MUE of one for additional prostate lesions

[13:27] Scott: Fair enough. Obviously that is a very high-value service, so I'm sure anybody doing PAE takes notice when they hear that. Bottom line is documentation: make sure you have the medical necessity that supports the two codes if you're billing them.

Let's move on to our final question. We had a question from Tori. Tori says, "Hi, what is PRS Network's recommendation when it comes to the MUE for 55715? It has an MUE of one and an MAI of three. It seems that Medicare is directly contradicting CPT's description with this MUE, since the code description says to use 55715 for each additional lesion, but it seems like Medicare is saying 55715 should be billed once for all additional lesions that are biopsied. What is your guidance on this? Are practices successful in appealing this when billed with multiple units, or is it best to just bill one unit of 55715 for traditional Medicare? Thanks." Mark, we should probably go through the alphabet soup of this and also the description of the code.

[15:02] Mark: All right. Let's start with the code. 55715, as Tori indicated, is for a biopsy of the prostate for each additional lesion. It can be used as an add-on code to any of the MRI fusion codes or any of the MRI-guided biopsy codes, whether transperineal or transrectal. So it is not approach-specific, but it is guidance-specific. It is not a code that can be used with the straight ultrasound codes, 55707 and 55709. But it can be used with the MRI fusion codes, 55708 and 55710, and 55712 and 55713, which are both target lesion codes, versus 55708 and 55710, which are targeted lesion plus systematic biopsy. It can also be added on to 55713 and 55714, which are used for MRI guidance. And I may have said 55712 and 55713 for the MRI target; it's really 55711 and 55712 that are the focus for those. But it's an add-on code, it can be used in conjunction with MRI fusion or MRI guided, and it is for the second lesion and each additional. That's CPT guidance.

Medicare layered in the MUE, the medically unlikely edit, of one. I agree with Tori's comment that it's definitely counter to what CPT intended with the code. They also added the MAI, the MUE adjudication indicator, of three. An MAI of three basically means the computer will typically deny the claim, or kick it back with a request for medical records. So it's an automatic denial if you're billing more than one based on the current MUE. This is something Medicare recently added. They may have assumed the prostate typically has no more than two lesions, or they may have just decided to complicate everybody's lives, which seems to be the current MO for all the payers as they flex their muscle a little to make it more difficult to be paid accurately.

Given the CPT definition, at this point in time I would recommend that you bill according to CPT the appropriate number of additional lesions, even if it is above one. I would not stop at one. If in fact you performed target biopsies of three or four or five lesions at the same encounter, whatever the number is, and you have clear documentation identifying, on the previously interpreted MRI as well as during the procedure, that there are lesions or regions of interest clearly noted on the imaging that you are attempting to biopsy to find out what the lesion is caused by, those are things you want to document well. You will need to appeal those, so the documentation needs to be very clear that it is a third or a fourth lesion before adding additional units to 55715. I do not think you should try to navigate around this by listing 55715 on multiple lines. And I also think it is not appropriate to cut back to one if you have done three or four lesions. Go ahead and use the appropriate units and prepare for the record review before payment.

Why an automatic denial should be an automatic appeal

[20:09] Scott: Great. Questions, comments?

[20:11] Ray: I don't often say Medicare did something that may be right according to their rules, but you can see where they are pushing the identification of significantly different lesions to where you have to have it by MRI; you can't do it by ultrasound. So the MUE of one would deny all of those. Of course, they could do it by code number too, but that's Medicare. The MAI says, "If you did it right and it's by MRI fusion, then you should appeal it so you can get paid." So I agree, Mark. There are a number of these automatic denials that you should automatically put in for appeal, and this is one of them.

[21:09] Scott: It's kind of a bummer, because how much does 55715 actually pay, and how much does it cost to appeal? That's just a waste of money. It's a bummer that they set it up that way.

[21:24] Mark: Yeah, it's $47.10 if you're doing it in an ASC or a hospital. That's the additional for 55715. So it is definitely a principled appeal, and hopefully with some support from documentation, and potentially from the AUA and physicians, we'll get a change at some point from the NCCI group that keeps in touch with the MUEs. But we are where we are.

I would add that the MUE blocks, and the different focus a payer has versus what CPT puts in place, came up recently in our discussions about PCR. So it's not limited to the prostate biopsy codes. MUEs have been an issue we've discussed with stent exchanges and retrograde pyelograms. It falls into a number of spots where we have competing goals: CPT trying to make the coding system accurate to the level that we can track things and keep an eye clinically on what the best treatments are, versus Medicare and their budgetary push, which is focused on bundling and cost of care. It's one of those areas where they're once again using a giant shotgun to solve what they view as a potential problem down the road. We'll have to make sure our documentation is in place and our protocols to appeal are there.

Sponsor and Mark's final thoughts on rising scrutiny

[23:38] Scott: Frustrating. All right, let's wrap this episode up. We want to thank ModMed for supporting us with this episode. If you're in the market for an EHR or a practice management system, go to modmed.com/prsnetwork for specials for our listening audience. Okay, let's get some final thoughts. Mark, final thoughts?

[24:00] Mark: First off, I'd like to thank all of our listeners for listening to our podcasts and our occasional rants as we go down these rabbit holes. Hopefully you find them helpful, and we definitely appreciate the feedback. If there's something we didn't answer fully, or there's some confusion out there, please ask us again. We're more than willing to have that discussion and provide what clarification we can.

The second piece I'll add is that no matter what you do on some of this stuff, there is going to be scrutiny. We've seen that across the board with downcoding and with medical record requests. Instead of life getting easier, it seems to have gotten a little more difficult as these payers ratchet down. The whole focus by Medicare now on fraud and abuse, and the wide net they're throwing out to catch it, is really ensnaring the 95 or 98 percent of folks who are doing things correctly. It's always been important to pay attention to your documentation and coding, and now, with automation assistance on both ends of the spectrum, the payer side and the physician side, I see this tightening continuing. It is going to be a bit of an exchange going forward. We're all going to need to buckle up, pay attention, supervise, monitor and double-check, like we've been preaching forever, but it's time to once again retrain, refocus, and spend the time and effort with your clinical staff as well as your administrative staff to get everyone on the same page.

Can our AI keep up with the payer's AI?

[26:14] Scott: Great. Ray, final thoughts?

[26:15] Ray: Good advice. Medicare's obsession with not paying for anything you do twice has really made this system complicated. And Mark, I have one question. As we move forward, is your AI going to be able to beat the payer's AI in reviewing all of this?

[26:38] Mark: I think it's not a question of beating but surviving. It's going to be a constant monitoring process, as we've seen through the years. You've said this millions of times: a lot of what we deal with is the same question, but the rules change on the back end, and that's the piece the system is built to support, unfortunately, the rule changes by the payers. Are we going to be able to do a better job of identifying these issues? Yes, I think we are. Are we going to have more issues to identify? Yes, I think we are. As long as we continue down this pathway, it's the chess game of, when they shift a rule, how fast can we adapt? How fast can we stay ahead of these things, or more importantly, how fast can we keep up with the changes?

You've caught me a little. We are going away for the weekend so we can all regroup, but it's been a long month of a lot of different talks and hearing a lot of controversies surrounding some of the shifts Medicare has made. We've had Botox, we've had PCR, we've had C9761. All of these things surround the fine-tuning and shifting of rules from Medicare, and the opinions from entities like the AHA and the AMA, to help us remain financially viable without having to worry about takebacks and all the other tools that are now becoming secondary and more widely utilized than they were in the past.

[28:42] Scott: I think it's so important that knowledge is truly power. If you don't have a good way of finding out all these things that are happening, you are in the dark and you're practicing in a silo. Our podcast, the questions that come in, the comments we can share, our monthly UPTP meetings, anywhere we can help get the information out to you all, and you share information with us so we're all learning together. It does take a community, especially with the payers constantly changing the rules of the game. All right, that's all we have for today's episode. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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