Key takeaways from this episode

• Do not swap 0816T for 64590 or unlisted 53899 because WPS GHA called the claim "unprocessable." 0816T (eCoin tibial nerve neurostimulator insertion) is an active, carrier-priced Category III code that every MAC must accept under HIPAA; the MAC can deny it as non-covered or experimental, but "unprocessable because of the code" is not a legitimate response.
• Look elsewhere on the claim for the real problem, then resubmit and call the carrier. Check any LCA for 0816T, and confirm diagnosis N39.41 (urge urinary incontinence) is covered under it; some MACs are applying PTNS or sacral neuromodulation crosswalks that block processing.
• Carrier pricing is slowing physician payment for 0816T, while facility payment is flowing. 0816T has an APC assignment, so facilities are paid across MACs; physicians are mapping it to codes with assigned values to get MACs to establish a rate.
• Whether you keep a co-pay after a denial depends on the contract, and timely filing and no-authorization denials are treated differently. Most contracts direct co-pays to be refunded when the denial is for timely filing (a practice-side failure), while co-pays, co-insurance and deductibles collected against a prior authorization can usually be kept; no-auth denials are also more appealable.
• You cannot bill global urodynamics under the interpreting physician who was not supervising. The technical component must be billed under a physician present in the office under direct supervision rules; MLN article SE17023 (revised 2/1/2019) allows the group to bill the global under the supervising physician on the test date, or to split it.
• Splitting UDS into TC under the supervising physician and modifier 26 under the interpreting physician on a later date pays the office the same as the global. Split billing fixes productivity and RVU accounting but adds complexity and the risk of never billing the interpretation, so build a work process for generating the 26 claim.
• Consider billing UDS globally if you are seeing modifier 25 denials. When the interpretation falls on the same day as an E/M visit, billing the global on the test date lets you bill the E/M on its own date without modifier 25, provided no cysto or other procedure is done that day.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 293, recorded June 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

WPS GHA calls 0816T "unprocessable"

[00:00] Scott Painter: On this episode, unprocessable claims and urodynamics global billing. Stay tuned. Welcome to episode 293 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Let's get started. We had a couple of questions come in about unprocessable claims and claims denied for no authorization or untimely billing.

Let's start with the first one. The question is: WPS GHA, which is the MAC, is denying claims for CPT Category III code 0816T, stating that it is unprocessable and to submit a new claim. They go on to say that we can't even submit records to appeal. Do I use code 64590 or unlisted code 53899? We're submitting the claim with diagnosis code N39.41. Thank you. All right, Mark, what do you see in this? What's going on?

[01:13] Mark Painter: First of all, I can answer the question about whether or not they should switch to a new CPT code right away. You should not. The issue of unprocessable, I can see why you'd go to that with a Category III code, but the Category III code is a valid CPT code. This could be a glitch in their system, which we've seen happen a lot lately with a lot of different payers that are playing games with changing their rules and implementing things, maybe not using the same standard approach and being as careful as they used to be.

So it could be just a glitch, and you just need to resubmit. But the reality of what you should do is really take a look at the full claim and what the denial reason was. If it is not a glitch in the system, it's most likely something else on the claim. Go back to any LCAs that are out there around 0816T. It certainly looks like the N39.41, that's urge urinary incontinence, may be where your problem is. Maybe that's not covered in the LCA. We'd need some more data to really figure out what's going on. But the first instinct of going in and changing the CPT code is not the right move.

Ultimately, all of Medicare is required to adopt all of the current CPT codes and HCPCS codes. That's a HIPAA requirement. They could deny the claim as non-covered or as experimental. There are a lot of different things they can do, but unprocessable because of the code is not a legitimate response. Chances are there's something else going on with this claim. I don't know exactly what it is, because we don't have all the information back. But I would look more deeply into this to find out why it was unprocessable. There may be some information included in your denial that can give you a clue, as well as taking a look at any of the other potential issues surrounding the use of 0816T.

That's where I would spend my time. I would take a look to see if there was anything in the claim that was missed. Otherwise, I would resubmit, and I would actually call the carrier, because changing the code to something else is not a legitimate move relative to this particular code, which is considered active in the current Medicare fee schedule. It's just carrier priced. So that is definitely not the action I would take, to change the CPT code.

What 0816T is and why carrier pricing slows it down

[04:23] Scott: I bet our listeners may be curious, for those that haven't memorized the CPT book, what the 0816T is.

[04:32] Mark: This is the code for eCoin: open insertion or replacement of integrated neurostimulation system for bladder dysfunction, including electrodes, array or leadless, and pulse generator or receiver, including analysis, programming and imaging guidance when performed, posterior tibial nerve, subcutaneous.

[04:56] Scott: And that has its own challenges, as we know.

[05:00] Mark: It does. The carrier-priced issue is always something that slows claims down. We've seen some claims now paying in different payers for the physician. There is an assignment of the 0816T to an APC, so payment to the facility is typically going smoothly across all MACs. But the carrier-priced issue has slowed down payments for the physician side of this, as physicians are starting to put this information in, mapping it to other codes that have assigned values, to get the payer to finally establish a rate for their carrier reimbursement relative to 0816T.

And then, of course, whether or not they're using PTNS coverage guidelines or guidelines that were applied to some of the other incontinence services we provide, like sacral neuromodulation. This may be where the problem actually lies, in that they may require some stress incontinence or block. We're seeing some crosswalks from other existing technology that we use to treat incontinence of various types being applied to some of these codes, and that's blocking some of the processing and some of the payment. I'm not going to say correctly, but unfortunately, that's what's happening.

[06:41] Scott: Ray, comments, questions?

Dr. Ray Painter: Nope, nothing to add.

Keeping co-pays after a no-auth or timely filing denial

Scott: All right, let's go on to the next question. It's another claim processing question. This comes in from Stephanie. Stephanie says, "Hello, I'm a new business office manager, and a question came up regarding patient-owed balances when a claim is denied for no authorization or timely filing. Are we able to retain co-payments and co-insurance or deductibles that have been collected, or would payments need to be refunded to the patient?" It's an interesting question. What do you have, Mark?

[07:25] Mark: Is it? Well, unfortunately, my answer is it depends. It really depends on the contract. I would say that most contracts that we've looked at have a clause that says the co-payment for services that are denied for timely filing typically is directed to be returned to the patient, or refunded, based on that contractual language. So it's not something that is governed overall by general rules of CMS or CPT. This is contract language, because it's about the timely filing of the claim. You don't have some of the same issues relative to Medicare if you don't timely file. There's nothing specifically there if you had pre-collected, because most people don't relative to Medicare on co-pays. Someday down the road that might become an issue, but that is something that overall you're going to want to take a look at.

Relative to your contracts, which is, I think, where most of this question is directed, you're going to have to look at your contract relative to co-payments. Now, your co-insurance or your deductibles and your co-payments that you pre-collected relative to a prior authorization, typically those under contractual language are allowed to be kept. So that's one of those little nuances that you'll have to look through your contract for, and they're not the same. I know it got grouped, and we look at those denials as flat-out denials, sometimes hard to appeal, and sometimes we lose. Obviously, timely filing cutoffs are becoming much more hard-line over time, and so are prior authorizations or no authorizations.

But we have had some cases where we've been able to overturn no-auth or prior-auth misses. It does require some lift, and it doesn't work all the time, but it's definitely worth trying for. The timely filing issue, that one is a fail on the physician side and/or physician office side. Ultimately, that's one where I'd probably look at pushing the refunds out unless I have a contractual allowance to keep some of those things. The authorization side, I would say, is far more flexible based on what we see in the contracts, but you should double-check your contracts.

[10:21] Scott: Ray, comments, questions?

[10:24] Ray: No, just a comment that it just doesn't seem right. If you provide the service, it looks like you ought to be able to keep the co-pay even though you didn't do timely filing. But the rules are the rules.

Can urodynamics be billed globally under the interpreting physician?

[10:41] Scott: All right. Let's go on to our final question. This came in from Tori, and Tori said, "Hi there. I need some clarification, please. This was briefly discussed on podcast episode 88," so that was a while ago, "and it referenced the Medicare Learning Network MLN article SE17023, revised 2/1/2019. Typically, we do not split for UDS. We have been billing globally under the supervising provider when the technical component is performed. The issue with this is that the ordering provider later interprets the results and does not receive reimbursement for this, since it was billed globally under the supervising. Is this MLN article suggesting that it is okay to bill the global service under the interpreting provider, on the date the UDS is performed, even if they are not supervising the service? We are a group practice, so all providers bill under the same tax ID, but I thought it would be very incorrect to have the interpreting/ordering provider's NPI in the supervising provider position on the claim when they weren't there to supervise. Help, please." All right, Mark, I know you've talked about this, and Ray, I know you've talked about this a lot in the past. Has the answer changed or not?

[12:16] Mark: It has over time, but not since the 2019 podcast. First of all, Tori, thanks. Episode 88, that's over 200 episodes ago. That's pretty impressive, and thank you for listening that long. But the easy answer to the question she asked is no, you cannot bill the global under the interpreting physician. The supervision requirements for the technical component are very clear. We do have flexibility, though, on how we bill the remaining portion of the urodynamics, and that's what that article was all about.

Medicare has, over the years, bounced around a little bit in how they handle codes that have a technical component and a professional component. They're very clear on laboratory services that the date of collection of the specimen is the primary date that is billed. As with any rule, there are general exceptions: when you collect a specimen and order a test days later, you can run it on the test date. So there's a little bit of variation there. But generally speaking, the date of collection of the specimen is the bill date for any laboratory services. Unfortunately, that's one of those things that creates problems when we're dealing with some of our PCR RACs and all the other stuff, because dates of service don't line up with the actual test date. Sometimes people have submitted incorrect records because they focused on the wrong information. So it hasn't really solved a lot of problems. In fact, it's created some. But that's an aside. I'll try not to go too far down that rabbit hole and go back to the question at hand.

For those services which have a professional and technical component, Medicare has made it very clear that the supervising physician for the technical component has to fit under our general incident-to or direct supervision rules. The technical component has to be billed under a physician that was in the facility on that date. They did give, however, because it's the same tax ID number, the option for the practice to bill the global on that date under that supervising physician. That creates a little bit of an accounting issue, and that's what I assume they're up against here. If you're calculating your physician reimbursement either on the gross collections or on RVUs that come into the practice, you've got to be careful how you assign those, and it's hard to do that within the practice management system if the global falls under the supervising physician, because the physician who did the interpretation, or the work relative to that, is under the professional component.

Split billing versus global: dealer's choice, with a modifier 25 wrinkle

Medicare recognized that these are different work efforts. Ultimately, there were changes in the RVU structure for urodynamics codes a few years ago, it's got to be ten now, in which it really doesn't matter, as far as the overall payment, whether you bill this on two different dates: one, the technical component with the supervising physician, and the second date of service would be the professional component, or the 26, billed under the interpreting physician. It pays the office the same as if the office billed the global component, so all the urodynamics codes with no modifiers on the date the test was provided, billed under the supervising physician. This is essentially dealer's choice within your practice. I would recommend, if you're having accounting issues with those, that you do split those and bill the technical component under the supervising physician and the 26, or the professional component, under the interpreting physician.

That has changed over the years, but this MLN article in 2019 has held since then, and it allows us to do that. So you need to develop that system so that you don't miss billing the professional interpretation. That's, I think, the bigger risk to the practice: we've got the service occurring, and your technician puts that TC in. Then when the physician opens up and reads the note or does the interpretation, somebody's got to generate that bill, so there needs to be a work process in that case.

The other thing I'll put into the mix that you might want to think about is that we are seeing more and more denials on dates where a 25 modifier is used on an E/M code. The interpretation is often done on the same date as the E/M visit by the interpreting physician. If you're having issues with that 25 modifier being denied on those, that would be another reason to think about billing it as a global and then billing your E/M service on that separate date, if you're not doing a cysto or anything else, so that you can bill that E/M without a modifier 25.

[18:24] Scott: Great. Comments, questions?

[18:26] Ray: You answered my question before I asked it. My first question when you went through this was, is there any harm or any reason I shouldn't just bill the supervising physician on the day it occurred, and if three or four days later the same doc was to interpret it, why not just bill him on two separate days? I know you have the option, but you could standardize it in your practice. And then you turn around and give me the 25 issue, and that answered it. You probably should use the global if you can, right?

[19:09] Mark: Yeah. From an overall practice flow standpoint, you're introducing complexity by split billing it. Complexity could lead to misses. And then, of course, the second complexity you're adding is, is that E/M code going to get paid? Those two things might drive a practice to say, "Let's just bill it as a global under the supervising provider, and let's deal with the reimbursement or remuneration to the physicians in a separate bucket," assigning things a little bit differently. That's within your system. Can you do that? Those are the balances that you need to weigh.

Sponsor and final thoughts on contracts and the shifting market

[19:58] Scott: All right. Let's wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. All right, let's get some final thoughts. Mark, final thoughts?

[20:22] Mark: I'm going to skip talking about the urodynamics and really talk about contracts and some of the issues we covered relative to the denials that we're seeing in the marketplace, in this case prior authorizations or timely filing, and then looking a little bit deeper into those issues related to HIPAA and CPT codes. It was interesting: right before the podcast I was reading through a couple of articles trying to see what's happening in the future, looking down the road a little bit, and I was answering some questions for some clients as well. We've got the proposed rule coming out in a couple of weeks. It'll be interesting to see what Medicare's going to propose and whether or not there's going to be some type of fix to the Medicare fee schedule conversion factor. So we've got a lot of things up in the air with Medicare next year.

But the interesting thing in the article I read was, as we're once again facing double-digit increases in insurance this year for employers, and we're starting that process as well, which is why it popped into my head, the market is shifting a little bit. There's a discussion about whether or not networks are really the answer, or networks are really just the way we do things and we're entrenched with that. There are insurance companies that are doubling down on networks, but there are also moves within the market in which the employers who are paying the bill are moving more toward direct contracting and using payers to administer their programs. There was an agreement recently signed in New York that was a direct contract to an orthopedic specialty for that specialty's care, again to try to control cost based on quote-unquote value provided by specific provider groups or physician groups. So there is some churn out there as everybody's trying to solve the cost of healthcare as we move forward.

That, I think, is part of the issue we're dealing with, with the payers that are out there right now with these additional denials, the tightening up of prior authorizations, and the issues surrounding timely filing and the accounting that goes with all of that, depending on who is actually paying the bills or who is administering the program. The self-funded programs fall under a different rule set. ERISA plans or direct contracting allow more flexibility. So as we look into all of this churn in the marketplace, it really does fall back on the physicians and the physician groups to figure out how they can present their pathways, their treatment protocols, those types of things that are systematic and measurable, to win some of these contracts as they start to grow within the marketplace.

They're all through TPAs, so it may not be something that you see directly. It's based on measurements from those insurance companies who are denying our claims everywhere else, measuring the value, in air quotes, that is assigned to each of those provider groups. This is just another piece of this equation that's truly making this very complex and complicated, and emphasizing to me, once again, the wheel of fortune: that the clinical side of this and its marriage to the coding, documentation, and reimbursement is just becoming more and more important in everything that we do. So it's worth taking a look at the overall process and making sure that you're communicating well from top to bottom in the revenue cycle picture.

[25:03] Scott: Agreed. Ray, final comments?

Ray: Amen.

Scott: All right. Short and sweet and to the point. I like it. That's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding and billing and documentation.

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