Key takeaways from this episode

• WISeR (Wasteful and Inappropriate Service Reduction) brings prior authorization to traditional Medicare on January 1, 2026, in six states: New Jersey, Oklahoma, Ohio, Texas, Arizona and Washington. It is a CMS Innovation Center demonstration running through December 31, 2031, and it applies to physicians, APPs and suppliers.
• Three urology service lines are in scope: incontinence control devices (including bulking agents and artificial sphincters), sacral neuromodulation (64561, 64581) and evaluation and treatment of male impotence. The governing coverage policies are NCD 230.10 (incontinence control), NCD 230.18 (sacral nerve stimulation) and NCD 230.4 (impotence).
• Participation is "voluntary," but the alternative is worse. If you skip the prior auth from the "model participant," the MAC will request your records before paying, which slows cash flow; the practical path is to build a workflow checklist per service and get the auth up front.
• The model participants are paid per denial. Their fee is a share of the average regional reimbursement for each upheld denial, reduced for denials overturned on appeal and for patient satisfaction, so the incentive is to deny. Contractors will likely be named in the October to November timeframe.
• Documentation and persistence win prior auth fights. Ray's experience on UnitedHealthcare's national advisory committee showed prior auth works as a speed bump; physicians who answer the questions and push on the back end get care approved, and inappropriate denials must be appealed.
• Medicare's sacral neuromodulation NCD is already out of step with the updated SUFU pathway, and the 2026 proposed rule discounts RUC survey data on physician work. Advocate through your specialty society and state medical association.
• For C9761 (steerable vacuum aspiration), document in the operative note that a steerable, suction-assisted device was used and why it was medically necessary. C9761 is a facility code only; the device and invoice should be reported to the payer so the device offset is known.
• Facilities are billing and being paid C9761 with non-Calyxo suction sheaths such as ClearPetra, and the "a catheter is a catheter, steerable is steerable" argument would likely hold in front of an ALJ, but it is still an argument. An ALJ win applies only to that one claim, and RAC review remains a risk on a high-dollar facility payment.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 255, recorded August 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network, and guest Dr. John Lin.

Welcome back, Dr. John Lin, and the Thriving Urology Practice group

[00:00] Scott Painter: On this episode: is Medicare really getting wiser, and catheters that suck? Welcome to episode 255 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 want to welcome back special guest Dr. John Lin, a solo practitioner in Gilbert, Arizona, and the founder of the Thriving Urology Practice Facebook Group. John, do you want to tell our audience about the Thriving Urology Practice Facebook Group, for those that don't know about it, and how they join?

[01:00] Dr. John Lin: Well, I can't wait to provide more value to our audience. The Thriving Urology Practice Facebook Group is a free Facebook group where like-minded, US-based urology practices get together to share information, because I hate keeping information behind a paywall. It is free. Did I say that already? If it's free, I'll take three. Or, if it's free, it's for me. And vendors, I know some vendors will listen to this podcast and think, well, I want to join. Sorry, only urology practice people in the US: urology practices, MAs, office managers, physicians, APPs, that's pretty much it. I wanted to create a safe space for everyone to freely discuss what they like, what they don't like, tips and tricks on how they can grow their practices and continue to survive and thrive in today's hostile environment.

Scott: All right. Well, John, we really appreciate you joining us today on this episode. Let's start by talking about the WISeR program, which stands for Wasteful and Inappropriate Service Reduction. It's a new program coming in 2026 from Medicare. Do you want to share what you know about this?

What the WISeR program is and who it affects

[02:00] John: This came on my radar several weeks ago. I made a post about it in the Facebook group. It's a little bit concerning. I'll just give you the bottom line up front, which is, believe it or not, something the military adopted. WISeR is a new CMS Innovation Center project that creates hurdles. This is my perception: it creates hurdles for urology practices, which will then delay care by implementing prior authorizations. Yes, prior authorizations for traditional Medicare. These are the three things that affect urology: number one, incontinence control devices; number two, sacral neuromodulation; and number three, impotence devices, among others, in certain states of the union.

So what are some of the details? First of all, it's a demonstration project by the CMS Innovation Center, and as you said, Scott, it starts on January 1st, 2026, in about three and a half months, and it lasts for six years, ending on December 31st, 2031. Who does it impact? Providers, physicians, APPs and also suppliers. Now, why did they do that? The purpose is to save CMS and taxpayers money by reducing inappropriate use and possibly fraud, waste and abuse. What does it involve? Initially, for this go-round, for next year, it'll involve six different states: New Jersey, Oklahoma, Ohio, Texas, Arizona and Washington. If you're in one of these six states, starting January 1st, 2026, you are going to need to pay attention to this. But those of you who are not in those states, stay tuned, because it may roll out much sooner than you would like. As I already mentioned, only three of those service lines involve urology: the incontinence control device, sacral neuromodulation, and evaluation and treatment of male impotence.

Let's just consider the impact. I figured out some numbers and determined that just within these states, the Medicare beneficiaries are about 68.8 million people in the total Medicare beneficiary pool, and that's about 18.5 percent of the total eligible beneficiaries that will be included in the WISeR program. That is a lot of Medicare-eligible people. Now, not all of these Medicare-eligible people are in traditional Medicare, because this program does not impact those in the Medicare replacement plans, falsely known as Medicare Advantage plans. I call it Medicare Disadvantage. Currently about 51 percent of eligible beneficiaries are in the Medicare Advantage program. So let's just say about half of the people in the eligible states are going to be involved in the WISeR program.

How does it happen? Starting January 1st, 2026, if you're thinking about providing sacral neuromodulation, an incontinence control device, or male impotence services, there are a couple of ways to go about doing it. One, you can get a prior auth from, and get this very important phrase when you start reading about this stuff, "model participants." You have to get prior auth from model participants before providing the service to avoid denial of payment. Or, number two, which I think a lot of practices are unfortunately going to be defaulted into: you take your chances and provide the service up front, then try to get the prior auth, or post-auth in this case, hoping that you get "affirmed," another euphemism that they use in the program. Hopefully you get affirmed on your claim and get paid. So, one, you get the prior auth beforehand; two, you try to get the authorization afterwards and hope and pray that you met the criteria to get paid.

And what are the model participants? Model participants are these qualifying companies that perform prior auths. Think Medicare Advantage prior authorization programs, because CMS is looking for partners such as those already in place with Medicare Advantage programs to perform prior auth using artificial intelligence, machine learning, and lastly humans, to once again affirm, or as I like to call it, authorize, or "non-affirm," as they call it, which is simply another euphemism to deny payment for services. And this is what's so perverse and misaligned about this entire program: how are these model participants paid? They're paid by the number of appropriate denials that they provide. Yes, they are paid by the number of appropriate denials that they provide, multiplied by the average reimbursement for the region for the denied claim for the year, minus some performance measures such as initially overturned denials that are then approved on appeal, plus patient satisfaction. So basically, the bottom line is, the more they deny, the more money these model participants collect. Anyway, that's the long and short of it. Mark, what are your thoughts?

The incentive to deny, and "voluntold" participation

[09:00] Mark Painter: Well, you summed it up pretty well. The incentive is to deny, so it's going to be interesting to see how they set it up. They're really trying to lean into AI, so these companies are going to be fairly light on humans and human support. This whole process of prior authorization is going to be done by machines. And we don't know yet who's winning these contracts, so we don't know who's going to have each state. They're going to be awarded in three-year deals, so these guys are going to be in place for three years when they get the awards, and then they've got to renew based on how they perform, or, on the other side of the coin, did they make enough money? These guys are leaning into this as a gamble as to what they can and can't get as far as money is concerned. The target list that Medicare came up with is really targeted toward areas where the RACs have been busy over the years. You can see how they connected those dots.

And then the alternative. It is, quote unquote, voluntary. You don't have to participate in the prior auth. But it's more like voluntold, because on the back end, if you don't get the prior auth, the MAC is actually going to request your records before you get paid. We're all used to this with the Medicare Advantage plans; they all have this. So this is Medicare copying the move of the private payers by adding prior authorization. If they have success, meaning they've denied lots of coverage to patients who didn't fit the criteria, then they're going to roll this out, probably to more. That's the other side of this that's going to be of interest. The flip side is that the MACs are now going to eat a significant amount of chart review going forward for those who aren't participating with this prior auth piece. I'm assuming they're going to try to roll out or name the programs in the October, November timeframe. So you lucky people in Washington and Arizona and Ohio and Oklahoma are going to have a shot at least at preparing for this, and of course the big one, Texas. This is going to be an interesting experiment across the board.

The other one, and I asked John a little bit before we started: how are they going to set up a prior auth based on the NCD for impotence? It is a very thin directive from Medicare that doesn't really have any solid guidelines. Now, sacral neuromodulation, we all kind of know what's there, the failed two drugs, and so on. So that one is generally something we can look at and see how they would put the AI in place to drive a prior auth for that particular service. In some ways, that might protect a few of you up front from takebacks down the road, because we've seen that happen, and hopefully everybody's got all their boxes checked and they're ready to go. Workflow-wise, what we're going to end up seeing, because we're patterning all of this to AI, is how do you build a workflow checklist for each one of these areas where they're going to roll this in? And yes, do you participate? I would think so, because that payment delay on the back end, with a chart review or medical record request, does slow down your cash flow for those particular devices. So it is going to be a workflow issue. I think there's a way around it, and it's not like we're unfamiliar with prior authorization. Unfortunately, that is now becoming sanctioned by Medicare, so it's probably going to be everywhere pretty soon. I think it's going to expand.

[14:00] John: Yeah. This is a big departure for traditional Medicare. In the past they haven't really done a lot of prior auths, but now this is a big step: six different states, 19 percent of eligible beneficiaries in those states. And for those of you who are listening, RAC means recovery audit contractor. These are bounty hunters looking for mistakes that you made, and they make money by catching you making those mistakes. MACs are Medicare administrative contractors. I believe there are 16 in the US that administer payment to your practices. We like to throw a lot of acronyms and shortcuts around, but I want to make sure the audience understands, because everybody's knowledge level is different.

Mark: Yeah, I appreciate that. You definitely get how, when you participate in conversations in different areas, sometimes you walk away thinking, I didn't understand a thing those guys said, because they used too many acronyms. So thank you for that. I forget that, even though I've experienced it on the other side.

Why these services were targeted

Scott: Mark, I've got a question for both you and John. You mentioned that a lot of these targets were subjects of the RACs in the past. Do you think the common theme for all of these is that they're very high-ticket, very costly devices and procedures? Is that the low-hanging fruit they're looking at?

[15:00] Mark: I think there are a couple of things behind this. One, yes, they are high-ticket items. Two, they've got the data, because the RACs did recover a lot of money going after claims and reviewing them after they'd already been adjudicated by the MACs. So essentially, if you step back into their shoes, you say, look, we gave physicians trust and they abused it, and we gave the MACs trust and they didn't watch Medicare's money the way they were supposed to. We found that out by paying these folks to go and look at things, and they recovered a lot of money. So this is an obvious next step. We see it in the private sector, so it's one of those easy political sells. They're reasonable-volume services, not ultra high, but reasonable volume. And the geographic spread gives different types of geography; it spreads it throughout the country to some degree and puts it under different MACs, the administrative contractors. From that standpoint, you can see the logic.

The other piece that's also big is that most of these areas have NCDs, national coverage decisions, that have been published. Not all of them; for some of them they're using local coverage decisions or local coverage articles and coding to focus on those areas, and those aren't necessarily ones we have in urology. The urology-based ones are all NCDs, but they expanded into things like knees and electrical stimulation and skin substitutes, places where they have other guidance published, so that essentially you're not turning these new innovations loose without a previously established Medicare payment policy or coverage decision that everybody has access to. So there's some weird logic in this from their side as they go through all of this. But it is money. That's the other part of it: they've got that backing that they've recovered money for services that were provided that didn't meet the criteria.

Scott: Ray, anything to add?

Dr. Ray Painter: Let's see. Was it Yogi Berra that said this is deja vu all over again?

John: So true.

Lessons from UnitedHealthcare, and whether the contractors will win

[18:00] Ray: You've heard me tell you before, I was on a national advisory committee for UnitedHealthcare during the time they instituted prior authorization. I was in a unique position, because at the same time the State of Colorado had a court-ordered advisory committee for UnitedHealthcare to look at things. So I was looking at things from the payer's point of view on the national level and from the provider side on the local level. From what we saw, those companies are going to make a lot of money, because if it fits the same model as UnitedHealthcare, those prior authorizations were more like a speed bump that some docs were not willing to take the time to go over. UnitedHealthcare saved hundreds and hundreds of millions of dollars in the first year or two they instituted that program. But in Colorado we proved that if a doc really needed that test and answered the right questions, they could get authorization at any time. So in this case, it's going to depend on the physicians as to how that really works. This doesn't compare to an x-ray that you could get or do without, probably. But if a doc really wants to get this procedure done for their patient, they should be able to get it done. So you're going to have to be diligent, do the documentation, and play the game by the rules, or else those companies are going to make a lot of money.

[20:00] John: Yeah. Ray, the problem is, the rules are nebulous, especially, as Mark said, the NCD, the national coverage determination, for impotence is vague, unlike sacral neuromodulation. So I guess it's a cat and mouse. The program's model participants, and of course they're not referring to us, the docs, they're referring to the authorization entities, have to come up with a set of rules. And we need to find out from them this fall, once the model participant entities have been selected. We need to figure out what they are. As soon as I find out, I'll share it in the Thriving Urology Practice Facebook Group. We need to figure out what the rules are so that, on our end, we can perform the necessary work, and also, unfortunately, the documentation, the bane of our existence, so that we can provide the necessary care for our patients. Humans are super simple; I figured this out. We want to thrive and survive in the easiest way possible. Whenever you put up hurdles, humans are lazy. Any time you put up a hurdle, we're less likely to perform that behavior. As you said, UnitedHealthcare and the insurance companies know this. Medicare knows this too. So I think this is just another way to deter performance of some of these services, because it's another hurdle that we have to deal with. Death by a thousand cuts.

[22:00] Ray: Thanks, John, for bringing that up, because I left out one key point I wanted to make, and that is, a lot of that work, as we proved in Colorado, is on the back end. You have to keep pushing for what you need to do for your patient, and eventually you'll get there. They don't deny good care for patients; they do deny requests for care. So whatever the rules are that are unreal, we need to fight it, and it's going to be up to you guys in those states to fight it first. You're setting the tone. So Mark, John, Scott: educate all these folks as to what they have to do. It's going to be important.

Scott: Well, the big winners out there are going to be these model participants, and the losers look like they're going to be a lot of physician and APP time, and the patients, who may have delayed care or may not get the care they need if the urologists and APPs out there aren't able to get that approved. There's got to be a better way, but that's what we have to deal with now.

[23:00] Mark: One of the things about the model participants in this: it's voluntary, right? If none of the physicians participated, and they were willing to put their records in to the MAC, if everybody said forget it, the model participants wouldn't make any money and the MACs would be buried in paperwork. It would slow down your payments. But is that a viable bite back in this whole thing? Or does the next move then become Medicare essentially saying, okay, we tried voluntary, you guys didn't play, now it's going to be mandatory without any testing? That's one thing I think is out there. The other one, of course, is that as they go through this, as with any game, if you know the rules, you can play the game. If you answer all the questions correctly on the prior auth, you get the prior authorization, you submit and get paid. And Medicare is going to say, do they still know that there are people out there, and one of the problems they're trying to guard against is the bad actors: okay, I answered the questions correctly, I got the auth, I got it paid for. But then are they going to go back and do documentation review to make sure the docs actually did what they said they were going to do? Which means they're still on the RAC target list on the back end. So I'm not totally convinced that these prior auth guys are going to win big. It's going to be a gamble.

[25:00] John: We're going to figure out how to appropriately document after providing the necessary workup and the service. The bad actors are also going to do the same thing, right? They're going to figure out how to do the documentation, beat the AI and the machine learning, so that they get the prior auth. And like you said, will the recovery audit contractors then come back, even though you've gotten the prior auth, with the intent to decrease fraud, waste and abuse? Even though you met the criteria for the prior auth and provided the service, will you be punished again by the recovery audit contractors coming back to audit your charts? Geez. That's crazy. That's a great point.

[26:00] Mark: Crazy. It'll be interesting to see which companies step up to become these project participants. That's going to be another piece that's out there. In some ways, do you want it to be the RACs? As a RAC auditor, if I'm thinking this is eventually going to replace me, I'm going to go into this side of the business as well, and then I can do both. I can do the front and the back, and I can start making money on both ends of the equation.

Scott: That's the long game for them.

Ray: Well, this should start with the specialty society, the specialists determining the appropriate care. Once that is established, we should be united in fighting for the rules to fit what's best for the patient.

Medicare drifting away from physician input

[27:00] Mark: We're already behind, right? Because SUFU totally redid the guideline, the pathway, for sacral neuromodulation, and it has not been added to the national coverage decision. This has been out for a couple of years already, and we're out of alignment, where Medicare has rules in place that are not matching the specialty society's recommendations of how to treat a disease state. So we're already mismatched.

Ray: That sounds like a Congress thing, saying that Medicare should align with specialty recommendations.

[28:00] Mark: Yes, I agree. And now you've got me wound up on the bully pulpit side. We're seeing in the proposed rule that the current approach CMS has taken is more or less to remove the physician decision-making process in work RVUs and practice expense RVUs, and now on this side, again stepping in to ignore what physicians are recommending for patient care. This is a drift that we've seen for a number of years, but it's culminating, or coming into place, right now, where we're seeing some significant moves by Medicare to start grabbing control of the Medicare ship. They've had a significant role in it before, but LCAs were one piece. Before, you had LCDs that required physician input, and they had 90-day reviews. Now, with LCAs, a MAC can just publish a coverage guideline telling you how to code for things without the same commentary, without the CACs. Remember the CACs? There's a lot of this that's been drifting that way, and this just seems like yet another step in trying to drive healthcare, as the payers do on the commercial side, from the financial side of the equation. More and more frequently I've heard this: who runs healthcare? Wall Street. Unfortunately.

Ray: That is getting scarier and scarier, because they've always had a jaundiced eye toward physicians being involved in the payment issue. Mark, you know that from the time we dealt with relative values back in the eighties.

Mark: Yeah.

[30:00] Ray: And the late seventies. They were trying to take physicians out of the equation on the payment side. But it's really scary if they're trying to take physicians out of the equation on the clinical side of medicine. That is a fight I think physicians should eventually be able to win, if we fight it in the right way.

[31:00] John: For those of you listening who are a little lost in the translation there, I'll try to simplify it. What Mark is saying is that in the proposed 2026 physician fee schedule, CMS has kind of disregarded the stuff that we've been providing. Some of the emails you've been getting, "hey, tell us how long it takes, how much effort it takes for you to perform a certain procedure," those are RUC surveys, relative value unit committee surveys. CMS has decided to disregard the information you provide regarding how much work it actually takes to perform a particular procedure, and then take that into account when they value your services. Don't get me started about being gaslighted into thinking that your value is dictated by somebody else, but I digress. So your value is now not being dictated by what you suggest, but instead by some seemingly arbitrary valuation by an entity. That's what's going on with the 2026 proposed physician fee schedule. And LCA is local coverage article, and LCD is local coverage determination, to decipher some of the acronyms.

Scott: More lingo.

John: Thank you again.

Final thoughts on WISeR: codes, NCDs and what to prepare

Scott: All right. We probably should move on to our next discussion. Any final thoughts on the WISeR discussion before we move on?

[32:00] John: Yeah. Number one, look for the list of CPT codes that will be impacted for the urology services. Look for the model participant list, and figure out how to engage them for the prior auths in the fall of this year for the six states involved. As Mark said, be aware of the LCDs and NCDs for the involved services, and definitely figure out what you need to provide for the necessary documentation. Be mindful, just like any other claim; be watchful for inappropriately denied claims. That is what is going to be really important to you. You will need to scale up your billing, maybe your prior auth team, if you perform a lot of incontinence device, sacral neuromodulation and impotence services in 2026 for Medicare beneficiaries. As we already said, documentation is key. Appeal the inappropriate denials. And very importantly, we need to advocate collectively. As Mark, Ray and Scott have said numerous times in prior podcasts, we have to participate in our societies and contribute to the political action committees. At the very least, you should be part of your local state medical associations. And the nuclear option, not a favorable suggestion, is to get out of Medicare, opt out of Medicare, go cash-based, so you don't have to participate in this game. I'm just thinking out of the box for all of you.

Scott: Mark Painter, final thoughts on WISeR before we move on.

[34:00] Mark: The thing I'm going to lay out there is, obviously, as we look at this, John's right, we'll narrow down the CPT codes. We'll be announcing that as well and really trying to keep everybody up to date. But as you're thinking about all of this: generally, you're thinking about sacral neuromodulation, so that's your 64561 and 64581. Those codes are going to be part of this program. On the incontinence side, any bulking agents are going to be a part of that; that's part of the NCD, so that's another big one. And then, of course, any impotence treatments, with that vague one that's out there. That's going to be another one we're going to have to navigate. Those are the broad categories that are out there, and artificial sphincters obviously are in that as well. So those are the areas you're going to be leaning into. You should take a look at the NCDs that are out there, the national coverage decisions, just so you know them. The sacral neuromodulation NCD is NCD 230.18. The incontinence control devices NCD is 230.10, and impotence is NCD 230.4. You can put that into Google, or your nearest surfing mechanism, and bring up those national coverage decisions, and you can see what we're talking about. It's going to be interesting to see how they translate that into a prior auth AI.

Scott: We'll also put those on the episode page, if you're someplace where you can't write those down and don't remember them. Go to prsnetwork.com/255 for episode 255. Ray, anything to add?

Ray: Well, we talk about getting paid a lot, but we want to keep in mind that our main goal is good patient care and taking care of those that need us. So don't lose sight of that as you're going through this fight for what's right.

Catheters that suck: C9761 documentation and which devices qualify

Scott: Very important. Okay, let's move on to the second thing we wanted to talk about. John wanted to ask Mark a question. Let's talk a little bit about catheters that suck.

[36:00] John: This is a repeated question asked by a lot of folks in the Thriving Urology Practice Facebook Group regarding the steerable ureteral catheter for tackling large stones: the documentation requirements, and for which device the facilities can use C9761, which is cystourethroscopy with ureteroscopy and/or ureteroscopy with lithotripsy and ureteral catheterization for steerable vacuum aspiration of the kidney collecting system, ureter, bladder and urethra, if applicable. In parentheses, the definition says: must use a steerable ureteral catheter. With the Calyxo device, it's very easy to say, oh yeah, we used the Calyxo, so facilities can use C9761 to get reimbursed. But what about the newer technologies, the newer steerable catheters that are out there, such as the ClearPetra? Others have one as well. What about those devices when you use them? And some of the docs are struggling with the documentation requirements. What say you, Mark?

[38:00] Mark: Okay. Number one, let's go to documentation requirements. You are going to need to mention in your note that you used a steerable device, a steerable suction-assisted device. That is one thing that is going to need to be added into your operative note. You're also going to want to make sure, obviously, as with everything, that the medical necessity was there. Why did you choose to do that? That should be in most of your notes, and when I see that, it's clearly that you've got a heavy stone burden, you've got big stones. There are a number of different reasons why that makes sense. But do add that additional information that that technology was utilized. I think it's debatable overall whether that is something that really should be required, but I really recommend that you do that.

Then, with regard to the different types of options we have right now, I do know that there are lots of folks that are using C9761 with some of the sheaths and some of the steerable catheters that are not Calyxo, which was the group that originally submitted the application for the pass-through technology, the TPT, the transitional pass-through technology code. Medicare and CPT always design their codes not to be specific to any one technology, but to a type of technology. So one of the things you've got to consider is the interpretation of that particular code. People are using it, people are getting paid. There is an argument that a catheter is a catheter and steerable is steerable, and ultimately that was the intent of that code. But the code does have that special parenthetical notation that it must be a steerable catheter. So the question becomes, as we move down the road, what are the payers going to do in that interpretation?

Now, most of what we're seeing there is a device offset, so the device should be reported to the payer. They should know exactly what they're paying for when Medicare pays for that. I think your biggest concern with this particular code is that Medicare and private payers are all over the board on the payment side, and that's going to be contract by contract based on your ASCs or with the hospital, because this is not about the physician getting extra payment; this is about the facility payment overall. So I do think there are some protections as you go through this. If you're providing the invoices, the payer knows what's going on, and the device offsets are set. To me, that gives me a little more comfort in using that particular code for the sheath, as long as that is fully disclosed up front and the offsets are paid by Medicare. You've got some precedent that, yeah, this was fully disclosed, it went forward, this is the way we're going to do it. Are the RACs going to come back somewhere down the road and determine that the MACs did it wrong? That's the question I have, and that's the one I don't have the answer to.

[42:00] John: Yeah. When Calyxo developed the original CVAC device, it was a steerable ureteral catheter, meaning on the proximal end you can turn and steer that catheter. But the new kids on the block don't have that steerability built into the catheter. Instead, they use a ureteroscope to steer the ureteral catheter into the appropriate calyces to suck out the stones. So is it steerable, by the definition of a steerable ureteral catheter? In my mind, ClearPetra and some of the other ones are being steered by a ureteroscope, so by definition they're steerable. That's one perspective that I have. Secondly, the second version of Calyxo's CVAC device: where is the catheter? Where's the steerable ureteral catheter? Because they developed a ureteroscope with a large suction port that's dedicated to sucking out stones and debris and clots, whatever. Is that a steerable ureteral catheter? If you're going to say it is, and facilities can use C9761 to get paid, then the argument goes, well, why can't the ClearPetra and the Dornier device be deemed a steerable ureteral catheter? So that's the question I have. If that's the case, then nobody gets paid.

[43:00] Mark: Right. Relative to all that we do in healthcare, it is relatively small on the scale. But it is that area where I think the arguments are there that fit those definitions, as you've laid it out: a duck is a duck. The intention of this was to allow suction-assisted devices to go forward and get paid extra as a transitional pass-through technology. And most people are required to submit invoices, or they are required to report what they're using. That's not necessarily true in some of your ambulatory surgical center situations, but it should be with the device offset as they roll through this. So I think there's, again, some protection there. I just want to add that note of caution that even though the argument is good, it's still an argument. That's where we always fall on these things: the vagueness. Can it win in a court of law under an ALJ? Probably. But in the end, that argument of going all the way up to the ALJ while your money's sitting in somebody else's pocket is never a fun one. I'd love to full-throatedly endorse that that's the right way to go, but I do have to add that note of caution that interpretation could be there. That argument may need to be made.

Scott: And that's a big dollar amount we're talking about. Again, it's on the facility side of things only, and that big dollar amount is what RAC auditors do tend to focus on. So that's the question in my mind.

[45:00] John: The problem is, without a clear path, a clear definition, to payment, facilities are reluctant to let urologists use this very powerful and effective device to clear large stones from a patient under a single anesthetic, which means the patients ultimately suffer without a clear definition on this code. As you said, Mark, it's not used a lot, but it's important for that patient with a stone burden.

Mark: Yeah, totally agree. Like I said, I wish I felt more comfortable saying party on, Garth, go for it. But I think I need to put that note of caution in, with the caveat that, yeah, a lot of that's being reported up front and endorsed by the MACs, seeing full well what actually is being utilized with that particular code, with the invoice offsets.

[46:00] John: And for those who are lost when Mark said ALJ: ALJ, administrative law judge, is a level of appeal when your claim is denied. I believe it's the third level of appeal. Unfortunately, I've had to deal with ALJs in the past, trying to fight for a claim that was over $8,000. Anyway, that's what that is. It's a third level of appeal, where you appear in front of a judge to argue your case on a denied claim.

Scott: And that applies to that one claim.

John: The ruling made by the ALJ applies to that one claim. So you can't take that ruling and say, hey, here's another denied claim in the future. Nope, it doesn't work. You have to argue that denied claim in the future completely separately from the denied claim that you won today.

Sponsor and final thoughts

[47:00] Scott: Yeah, it's crazy. Okay, let's wrap this up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com/prs for specials for our listening audience. All right, let's get some final thoughts. We're going to save the last word for John. Final thoughts, Mark.

[48:00] Mark: We've got a lot moving with Medicare. We got off onto a tangent a little bit as far as the proposed rule and everything that's out there. But for those of you in the states where the WISeR program is going to be implemented, it's another thing to add to the chessboard that you need to navigate and decide how you're going to go forward. So either play the game with the WISeR folks when they get that in place, or you're submitting your records to the MAC before you get paid. That's a choice you can make, and certainly, as we see these things roll out, probably the easier pathway is to go through the WISeR protocol to speed your money up. We'll have to see where those really lay down and what you need to put in place, but you can get an idea again by looking at the NCDs we gave you. With regard to Calyxo and the sheaths and C9761, that is one of those things where it's a calculated risk. It is a lower risk, I think, because you're submitting your information in for the invoice, but just know that there is some risk, and that may be the hesitancy of some of your facilities to work with you there. So do your part and make sure your documentation includes the fact that you used that scope with the suction assistance, and that it was steerable.

Scott: Ray, final thoughts?

[49:00] Ray: Well, some things change frequently, and yet it never changes. You have to be sure your documentation is complete and accurate for how you get paid, and follow up on all the claims. That's not going to change.

Scott: All right, and the final word to John.

[50:00] John: I know the purpose of PRS is to make urologists' lives easier, so our practices thrive, so we have time to enjoy our lives. To that end, I am going to quote something that Dr. Cheryl Shea mentioned in the Thriving Urology Practice Facebook Group, and that is: don't trade time you may not have for money you do not need. Understand why you are working the way you do. Understand your why, and do things that bring you joy. A lot of urologists want to do everything for everybody, and I learned long ago, whether that is urology or life in general, you can't make everyone happy. You can't be all things to all people. Do the things you enjoy doing and go all in, and just drop the things that don't bring you joy in life. That's going to help you have that lighter step as you come into your office, as you walk into the operating room. Pursue the service lines, the procedures, the patients that you enjoy seeing, so you can at least continue to play in this game and continue to work instead of burning out. Back to you, Scott.

[51:00] Scott: Great advice, and that applies to so many things. All right. We also want to let you know that the Urology Advanced Coding and Reimbursement Seminar is going to be in December in Las Vegas and in January in New Orleans, and it is super important this year to attend. You hear these discussions that we're having, and a simple hour on a podcast doesn't cover it. You need to come down, join us at the seminar, really participate, add your two cents, hear what others are saying, and figure out the best way forward for your practice. It's getting more and more difficult to practice the way you want to practice, and as John mentioned, you've got to really think about how you want to practice and what you want to do with your practice. One of the best ways to do that is joining us at the seminar, so you can really understand the landscape of what's going on. We have these discussions in detail with a group of very like-minded people who can contribute, who are in your same situation, and who can give you those suggestions you may not have thought about. Practicing in a silo is no longer an option in urology for anybody. It's just not there. So we encourage you to come down and join us. You can go to prsnetwork.com, and right there on the homepage, click on the seminar registration button and get registered. We'd really love to have you there. All right, that's all we have for today. Thank you all very much for listening. Take us out, John.

John: Happy coding, everyone.

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