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Key takeaways from this episode

• Do not appeal a bundled 74420 unless a separate, complete diagnostic radiology report was dictated. Payers following UnitedHealthcare's lead treat an image read that is only referenced in the E/M note as part of the visit's data scoring, so a global 74420 billed with an office E/M will be denied; 74420-TC is the fallback when there is no separate read.
• In the hospital, 74420-26 is paid to whoever bills first, and it is usually radiology. Before appealing, confirm you have the separate dictation, then check whether the radiology department already billed the professional read; coordinate with radiology rather than racing them.
• CMS favors the physician who reads the image at the point of service. A urologist who interprets the study during a procedure such as stent placement, and documents that read separately, has the stronger claim to the professional component than a later review.
• A 52356 denied as CO-11 with N13.30 needs a stone diagnosis, not unspecified hydronephrosis. Report N20.0, N20.1 or N20.2 for the stone location when there is no hydronephrosis, and N13.2 (hydronephrosis with renal and ureteral calculous obstruction) when hydronephrosis is present, for kidney, ureter or both.
• Avoid unspecified diagnosis codes on claims for procedures. Payers do not accept N13.30 as support for stone removal, so document the stone, its location and its size and code to that specificity.
• A modifier 25 appeal for 99214-25 with 52000 should argue the documentation, not the NCCI edits. The Aetna Medicare denial concedes the coding rule; the note has to show a significant, separately identifiable E/M with its own plan for BPH with LUTS (N40.1) rather than a quick decision to scope for retention (R33.8).
• Document a treatment plan that goes beyond the procedure result to support modifier 25. Starting medication, scheduling surgery or laying out a management plan for the underlying condition is what separates the visit from the cystoscopy's global.
• Modifier 25 remains the most scrutinized modifier in CPT, and the 2027 proposed rule does not change the documentation burden. Even if the proposed lower valuation goes through, the requirement for clear, separate, significant documentation will not go away.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 299, recorded August 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

A Blue Cross Blue Shield denial for 74420 billed with an E/M

[00:00] Scott Painter: On this episode: billing for radiological services in conjunction with office visits, diagnosis coding for stones, and finally, modifier 25. Stay tuned. Welcome to episode 299 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. On today's episode we're going to answer a few more questions that came in. They're great questions, and it's always interesting to see what's happening out there: what the payers are doing, what questions are coming in, what they're denying, and the different things you need to know and make sure you're doing in order to get paid for the services you're providing.

Let's get started. The first question is a Blue Cross Blue Shield denial dealing with code 74420, and the denial was "this service is included in the allowance for another service or claim." The question is: should this be appealed, or should the 74420 be adjusted off? Please provide rationale. The 74420 is urography, retrograde, with or without KUB. Mark, do you want to give a little more color on why they are asking that question? What did they bill with that?

[01:51] Mark Painter: We've got a few things here, and I'll tell you as we go through this question, we really need more information to fully answer it. But we do have a couple of different issues we can talk about. Let's assume first that this was done in an office setting. It was probably billed with an E/M code, because that's where the bundle comes into play in most of these cases. What we're following is what we saw with UnitedHealthcare coming out and saying the interpretation for any radiologic service needs to be clearly documented as separate from any E/M service provided on the same date of service.

So they're going to deny the global based on the assumption that the 26, the professional component, is part of the E/M, and the practice could go back and use a 74420-TC, and it probably wouldn't be blocked as bundled. That's one of the options that's out there. That would be if there is not a separate, deep-level interpretation, like a radiologic report of the 74420 read. So that's one issue that could be the blocker.

Now, if it's in a hospital setting, billing the 74420 without a 26 modifier would drop it out as bundled, because the facility typically gets paid for the technical component of the radiologic services. So just that 74420 as bundled could mean a couple of different things. And it looks like this was billed in a hospital setting. Is that a 99222?

[04:04] Scott: Yes.

[04:04] Mark: And they did bill the 74420-26. So in this particular case, you've got two other issues. But let's go back to the first issue. I want to remind everybody that when UnitedHealthcare put out their policy that they were going to start denying the interpretation of a radiologic service as part of the E/M, what they're really talking about is that the E/M code has a scoring under data for interpretation of an image. So what they're saying is, if you're just doing an interpretation of the image as part of your E/M, they're not going to pay you the professional component on the same date. That's double-dipping. In order to get paid for a global 74420 in an office setting, you need not only to have performed the service, but somebody needs to have dictated a clear and separate diagnostic report, and that needs to be included in any appeal.

Now, in the hospital setting, it does look like this claim was billed with a 26 modifier, so our issue isn't incorrect coding. This is a fishing expedition to explore the exact same issue, but in the hospital setting, with one additional caveat. The other caveat is: did the radiology department bill for the professional read of 74420-26? In which case it's bundled into their service, because it's already been paid to the radiologist.

So when you're in a facility setting, you've got to check both that you have that separate dictation that clearly demonstrates you did a separate and distinct diagnostic read of the image and dictated that full report, not one that's focused on the issues you're managing as part of the E/M code. Because you do have an allowance in the E/M code, that 99222, for the separate interpretation of that image that they would count as part of the E/M. In either case, the separate dictation is required. And ultimately, in the hospital setting, you're going to need to make sure your radiology colleagues didn't bill for that service separately.

Coordinating with radiology on the professional read

[07:03] Scott: Ray, comments, questions?

[07:05] Dr. Ray Painter: Mark, back in the old days we used to tell them, if they were going to charge for that, they needed to get their bill in fast. They had to be in before radiology. Is that still the case, or are the radiologists pretty speedy these days?

[07:21] Mark: I would say it is difficult to get things in ahead, but it's not impossible, and it depends on how good the radiology department is. They are going to pay the first bill in for the 74420-26, and it's always better to coordinate with radiology than to just speed past them, upset them and hurt your relationship. Having that discussion should be part of the process.

As far as this particular denial, I'd look at both. Number one, did I have a separate dictation? If I didn't, then I'm not going to appeal it. If I did have that separate dictation, my next step is: did radiology bill for this? Now I'm checking with radiology. But if I don't have the paperwork to support it, I can't appeal it anyway. So if you don't have the report, there's probably no reason to re-bill this code at all, because it's going to take an appeal to get it paid. If you've got the report, check with radiology, see if they got paid, and now you're in a discussion with the radiology department to decide if they want to retract their bill and allow you to bill, or maybe you can fix this going forward, in which case you wouldn't appeal it. Or if they're willing to retract their bill, you can bill for it under an appeal. So documentation first, then coordination.

[08:57] Scott: What's the likelihood of a radiology group or department agreeing to that? They're reading it anyway, right? They're putting in the work, and you're doing the same work they are. Why would they give that money to you when they did the work as well?

[09:21] Mark: That would depend, to me, on the negotiation skills of the urologist and the general attitude of the radiologist. The argument overall is that the urologist doesn't always get the report from the radiologist, so their read is really worthless to the treatment of the patient. On the other side of the equation, some urologists like to have the radiologic read to get a second opinion for the care of their patients. That's a balancing factor. And then of course there is the radiologist out there trying to hold his job and get his work RVUs. So they may hide behind a hospital policy or a bunch of different things. You might have a nice radiologist, but a department that's trying to protect their folks. There's just a lot of politics that comes into play in a hospital situation like that.

[10:27] Ray: We might add, Scott, that in this case CMS is on the side of the urologist. If the urologist read this at the time they were doing a procedure, in other words, they put in a stent and the image was read at the time the procedure was going on, CMS would like to see the individual at the point of service get paid, if they documented it. But if they were taking the report and looking at the image sometime later, then they shouldn't get paid.

[11:09] Mark: Yep. Then again, I'll add the caveat that the documentation has to be clearly separate and fully baked from a radiology report standpoint.

[11:18] Ray: Absolutely.

A 52356 denied for a diagnosis inconsistent with the procedure

[11:22] Scott: All right, let's move on to the next question. It states: they are denying 52356 as CO-11, the diagnosis is inconsistent with the procedure, but they paid for the other two codes on the claim. Not sure if there is another code we may use. What was billed was the 99222-25 with diagnosis code N13.30, the 52356-RT with the same diagnosis, and the 74420-26 with the N13.30. So first let's give everybody the alphabet soup, the codes and descriptions of everything. Then Mark, do you want to take us through it?

[12:31] Mark: Okay. N13.30 is unspecified hydronephrosis. That works for the hospital visit, which was a level two, which equates to a level four inpatient or outpatient visit, that 99222. The 25 was applied appropriately and paid, but I will say it was paid with a denied surgery, so there's no global. That might be an issue that pops up later as you go through the appeal, which ties into our next question, modifier 25 and what we're seeing on that. And then the 74420, of course, for the KUB we just talked about.

Number one, we have talked many times before that unspecified is a diagnosis code that is not appreciated by the payers. Now we look at the actual denial, and one of my questions would be: how would you do a 52356 if there wasn't a stone? In which case my immediate recommendation would be: why didn't you use an N20.0, N20.1 or N20.2? That's the diagnosis for stone. So one option is to switch that over to an N20 code, either N20.0, N20.1 or N20.2, depending on where the stone is located. The other one available is N13.2, which is hydronephrosis with renal and ureteral calculous obstruction. So you've got a few different options that would state clearly that the patient had a stone, which would be a reason to use a 52356.

[14:39] Scott: Ray, comments, questions?

[14:42] Ray: No, nothing to add. Good comments.

Choosing between N13.2 and the N20 codes

[14:47] Scott: So which diagnosis code will work better with the 52356, the N13.2 or one of the N20 codes?

[14:58] Mark: This is where you might be misled a little by the description. N13.2 is hydronephrosis with ureteral and renal calculus. But if you drill down from the N20.0, N20.1 and N20.2, it specifically says in the excludes category that "with hydronephrosis" is N13.2, meaning calculus of kidney with hydronephrosis should be N13.2. So if you've got a stone, the better-documented diagnosis would be the N20 code for wherever the stone is, kidney, ureter or both, but if you've got both a stone and hydronephrosis, the N13.2 is the one that actually works and should be the help there.

[16:04] Scott: So if they have hydronephrosis with a stone, and they do the 52356, and the stone's in the ureter, then which diagnosis do they use?

[16:25] Mark: Are the stones only in the ureter?

[16:28] Scott: Yep.

[16:29] Mark: N20.1 if without hydronephrosis, N13.2 with hydronephrosis.

[16:36] Scott: And it doesn't matter if the stone is just in the ureter or the kidney with the N13.2?

[16:43] Mark: That's the directive we see from the inclusion notes within the N20 series. So you would be justified using it for either the kidney or the ureter or both.

[17:00] Scott: All right. Ray, anything to add?

[17:03] Ray: Nope. Nothing to add.

An Aetna Medicare modifier 25 denial on 99214 with 52000

[17:07] Scott: Let's move on to the final question. Aetna Medicare is still denying the office visit. We've already done a dispute with them, which they denied, and it has the modifier 25 on there to separate it from the 52000. What was billed was the 99214-25 with a diagnosis of N40.1, and the 52000 with a diagnosis of R33.8. The verbiage used in the dispute that was already sent in is: "I submitted a dispute with procedure code 99214-25 denied as incident to 52000. Per NCCI edits, 52000 includes 99214; however, it can be unbundled with the appropriate modifier. Unbundling allowed with an appropriate modifier. Code 99214 is included in 52000. 99214 may be unbundled from 52000 if you can justify the appropriate modifier. If you are unable to justify the use of a modifier, you may only bill 52000. If you bill both, 99214 should receive the modifier. I have attached the supporting documentation and ask that the claim be reprocessed in a favorable manner."

Let's look at the diagnoses to make sure everybody understands which codes were billed with which diagnosis codes. We've got the 99214, which is a level four office visit, with an N40.1. And the N40.1 is...

[19:26] Mark: BPH with LUTS.

[19:28] Scott: BPH with LUTS. And then the cysto, the 52000, was billed with the R33.8, which is...

[19:41] Mark: Retention.

[19:44] Scott: Retention. So how do you break this down?

[19:50] Mark: I think the argument that was submitted was very factual from a coding standpoint. That's absolutely true. But my focus on an appeal like this would be more on the documentation supporting that it was significant and separately identifiable, which is noted as "I have attached the supporting documentation and ask that Aetna reprocess this in a favorable manner," but really not explained. What you're justifying here is probably not the NCCI edits. Those they know; that's why they pushed the denial through. So my recommendation would be that any further appeal, if you want to push this up to the independent reviewer, which isn't always successful but certainly worth a try depending on which payer it is, really focus on why that modifier 25 was significant and separately identifiable.

You've got a different diagnosis, but LUTS could include retention as part of that BPH with LUTS. So are you doing something really significant and separately identifiable from the cysto on that day? That's the focus of the denial, and if they've reviewed the note, that's where they're coming through with that. If I were going to appeal, I would want to make sure my note really supported that this wasn't a quick "Boy, you've got retention. Let's do a cysto and see what's going on. You've got BPH." Ultimately we need to think about a plan going forward.

It's really got to be more separate, that you did a significant service. A guy comes in, maybe you're following him for BPH with LUTS. You're not only worried about the retention, but you're also worried about what else is going on with that particular patient. You develop a full plan for treatment of that BPH with LUTS, not just that you resolved the issue that day. It really needs to be that full, separate and significant identifiable E/M that's not part of the global of the cysto, which covers the procedure itself, telling the patient what the procedure results are, and maybe scheduling another appointment. So you want to make sure you're really supporting that full, significant, separately identifiable service, because I think that's where the denial is focused. Not that you coded it incorrectly, but that the documentation didn't support your coding.

[23:01] Scott: Ray, questions, comments?

[23:04] Ray: Just to emphasize what Mark said. In the follow-up from the cysto, if you sit down and set up a plan of action, started him on medication or set him up for surgery or whatever, that's what your documentation should show, to show that was a significant and separate service provided in the E/M. And not just, "Hey, you need a cysto. We're going to do it. Yep, you had one. You've got BPH." That wouldn't get you paid.

Sponsors and final thoughts

[23:40] Scott: All right, let's wrap this episode up. We want to thank our sponsors for this episode. First of all, we want to thank ModMed. 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. Also, we want to thank UroGen, manufacturers of Zusduri and Jelmyto. If you want more information, you can go to jelmyto.com or zusduri.com. Let's get some final thoughts on today's episode. Mark, what are your final thoughts?

[24:24] Mark: I think we saw a couple of things today. We had three different topics, and all of them point back to our standard beat-the-drum: documentation. Making sure your documentation supports the diagnosis code. Really looking at all the language available in the diagnosis coding and making sure you're specific in your documentation. That one was a coding issue that we know of; we don't know about the documentation issue there. But definitely understand that, and that's a flag you could put in for your RCM team to catch those mistakes. The documentation issue of making sure you had the stone and the stone location is key, as well as the size. All of that needs to be there.

Then your documentation for your radiologic service needs to be separate and diagnostic in nature. And finally, modifier 25, the recurring theme, and probably the most talked-about topic on the Urology Coding and Reimbursement Podcast. Make sure that modifier 25 is clearly supported. It is the most widely abused modifier in CPT coding, and it is under the microscope, and we'll put it under the AI microscope. So make sure you've got clear, separate, significant, identifiable documentation. And of course, last week we talked about the proposed rule, which is one of those things we're going to have to keep an eye on. Whether it's going to be a lesser-valued modifier 25 or not is still coming up, but it still has value even if that goes through. So the documentation requirements will not go away.

[26:32] Scott: Ray, final comments?

[26:34] Ray: Well, if Mark didn't mention documentation, I will. Only kidding. But the other thing he made a big point of is, when you are appealing, be sure you are using your documentation to support the code or the modifier instead of just quoting the rules. Your documentation has to be there, and then you have to argue that it's there.

[27:08] Scott: Well said. I want to remind you all that the Urology Advanced Coding and Reimbursement Seminar registration is open. If you go to prsnetwork.com, right there on the homepage is a button to register for the seminar or get more information and pricing. Also, the PRS Urology Coding and Reimbursement Hub is available at prsnetwork.com/urologyhub, and on the hub is where you'll find the categories of various urologic services so you can look up how those are coded, and also specific products associated with those categories. We're improving that every week, so we encourage you to check it out and make it part of your search when you're researching coding and reimbursement options for different categories. That's all we have for today. Thank you all for listening. Take us out, Ray.

[28:16] Ray: Happy coding.

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