Key takeaways from this episode

• Effective April 1, UnitedHealthcare will not pay the professional component (modifier 26 or the global) of a radiologic service without a separately identifiable diagnostic report. The policy is written for radiology, but it keys off codes with a Medicare PC/TC indicator of 1, which also covers urodynamics, plethysmography and Doppler studies.
• The report has to follow the American College of Radiology elements. Describe the study or procedure, any contrast or radiopharmaceutical (activity, concentration, volume, route), medications, catheters or devices if not recorded elsewhere, the findings in anatomic, pathologic and radiologic terminology, and an impression stating a conclusion or diagnosis.
• Build a separate templated report for each of these services rather than burying the read in the E/M note. UnitedHealthcare will request records prepayment and its computer-assisted coding tools read the chart first; if you get a denial, submit the separate report and you can be paid on the global or 26. The technical component still pays without it.
• For urodynamics, staff can template the drugs, catheters and equipment; the physician's professional documentation is the findings (uroflow, contractions, when they occurred) and the impression. Then the E/M note documents what you are going to do about it.
• The habit to retrain is putting the impression inside the radiology or ultrasound report, not only in the E/M assessment. The E/M should show how the test result was incorporated with the history, labs and treatment plan as part of MDM.
• Records from another physician outside your practice pod (including the same network) count as data, but one physician's record is one data point regardless of the labs and CTs summarized inside it. Tests that arrive separately from that record, or an outside CT you independently interpret yourself, can each be counted separately; for the CT, document "CT scan was viewed and interpreted" with your findings (use "viewed" for images and "reviewed" for a report), and no separate report is needed since you are not billing modifier 26.
• An outside interpreter or translator does not count as a data point. The MDM credit is for an independent historian, which applies only when the patient cannot provide the history and someone else supplies it.
• Expect other payers to follow. Humana has already issued a denial asking for the same documentation, and payer contract rules, not CPT, are the actual payment rules to watch.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 281, recorded March 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

UnitedHealthcare's new professional-component documentation policy

[00:00] Scott Painter: On this episode: a new headache from UnitedHealthcare, and also some medical decision making clarification points. Stay tuned. Welcome to episode 281 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Today we're going to start by talking about an updated policy that's coming in from UnitedHealthcare that was pointed out to us by the folks at ModMed. We wanted to bring it to your attention because there is going to be a change in how your E/M and urodynamics and other PC/TC codes are looked at. So let's get started. Mark, tell us what's going on and what do they have to look out for?

[01:00] Mark Painter: First of all, in the column of "it takes a village," it's always good to monitor everything that comes from everybody. Sometimes we get information from sources that we don't necessarily expect, but there are definitely a lot of people monitoring everything that goes on with the payers. So it was great to see ModMed picking this one up, running with it and letting everybody know about it. Definitely pay attention to all sources. We're going back and figuring out how this slipped under the radar of all the monitoring of everything, but you just keep looking and keep finding things.

The policy is going into effect April 1st, and this policy from UnitedHealthcare is not really targeted to urology. It's really targeted towards the professional component of any of the radiologic services, and that's the way it really looks at it. But the way it truly reads is that it may be applied, and we're worried about this, to any code with a PC/TC indicator of 1 that is flagged as a 1 on the Medicare Physician Fee Schedule, or MPFS. They did put "a radiology service assigned to PC/TC indicator 1," but that indicator 1 does show up for urodynamics, for plethysmography and Dopplers as well. So it's something you want to look at. Now, this is something that ultimately we have been talking about for years in our coding courses, and that's the clear documentation of the diagnostic read of any of these types of services that you provide.

The policy basically states that because medical decision making, or MDM, includes data analysis and data interpretation as it pertains to the evaluation and management and treatment process, UnitedHealthcare is not going to pay separately for the professional component of any radiologic service unless there's clear separate documentation. The way they list documentation, which is based on the American College of Radiology guidelines, is that a procedure performed should include documentation of, specifically, a diagnostic report, and that report should include a description of the studies and/or the procedure performed; any contrast media and/or radiopharmaceuticals, including specific administered activities, concentration, volume and route of administration when applicable; medications, catheters or devices used, if not recorded elsewhere; the findings, and the report should use appropriate anatomic, pathologic and radiologic terminology to describe the findings; and then finally an impression, which is either a conclusion or a diagnosis. So all of that needs to be part of the professional component report that you need to develop for each of your radiologic services with indicator 1, and you probably want to look at this relative to urodynamics as well as your plethysmography and Doppler. That's the first part of this when you look at all the parameters.

The second thing is that ultimately it looks like United is going to request documentation of this as a prepayment requirement. If the documentation doesn't exist, you can still bill the code, the 7-series code or the other codes we talked about, with a TC, and those will pay. So you want to make sure that you're reviewing your documentation and that separate report exists within your medical record in some form or fashion. Whether or not it's a separate part of the medical record in which you put that note, or you bury it within your E/M, it really needs to be separately identifiable, and I'm going to recommend that it is a separate report so that it can be provided to UnitedHealthcare and their coding tools, which are computer-assisted coding tools. It's going to be read by the computer first. So definitely separating those out is the better recommendation. And I would recommend, obviously, that you build templates for each of these services and fill those out to make your life administratively as easy as possible.

If you get a denial for this, definitely review the records, make sure you've got those records, submit the records, and you can get paid on the global or the 26 modifier. And remember, there are times when you as a physician may be billing an E/M in the hospital and only the 26 component of a radiologic service. You'll need to make sure you have that separate note in the hospital as well, and your billing team will need to be able to get access to those so they can submit it in order to receive payment.

What the professional report needs to say

Scott: Ray, thoughts, comments?

Dr. Ray Painter: Yes. Mark, there's one part of United's rules that has me confused. It says your professional documentation has to include all of that technical stuff that's not reported elsewhere. So if I set up a template on each of my urodynamics to include all the drugs and the catheters and all that jazz that I'm going to use each time I do a urodynamics, and that's included in the documentation for that procedure, what do I say professionally as my documentation?

Mark: When you look at all of this, the clear part of this, what I would say is the professional component, is that you definitely have the "not recorded elsewhere," which means your staff could record what you referred to as mumbo jumbo. And I'm surprised you said only one part of that policy confuses you, by the way. But the real focus on this is you need to use appropriate anatomic, pathologic and radiologic terminology to describe the findings. So when you're looking at the urodynamics, you want to make sure that you're describing the high points, the uroflow, the contractions, and when that all was demonstrated within the report, and then your conclusion, your impression of what that report shows. That's the quick down and dirty. If your staff puts in all the other stuff, then you're going to focus on what the report told you as far as a general description, and then follow that up with whatever your impression is based on the radiologic information or the urodynamics information you were presented.

Ray: Excellent. You answered my question when you said findings and impression.

Mark: Yeah. And you're right, there is perhaps too much mumbo jumbo in all that stuff.

The habit that has to change: impressions in the radiology report

[10:00] Scott: So based on what you see currently, how the documentation is when we're doing our audits and those types of activities, what's the big change that providers are going to have to make? Is it going to be that separate note and those separate findings for that test or radiologic service?

Mark: I think that's a big one, making sure that you've got that separate note. But I'll say the other one that I see oftentimes is that a lot of physicians place their impressions within the medical record for the evaluation and management, and when they get into the treatment side, they don't actually put those findings in the radiologic report. So making sure the impression is part of the radiologic report, I think, is the one habit that needs to be retrained, if you will. Unfortunately, you're kind of putting things in two different places, but that also is part of the process. Based on that diagnostic test, that CT scan if you're doing it internally, but more importantly I think it's ultrasounds that I would see, you put that impression of what that ultrasound demonstrates with that report, in addition to any impressions that you got from the rest of the story, from the patient, their labs and everything else, and the treatment side. That's part of MDM. So it's separating the two: what did I learn from the ultrasound or the radiologic test, and then how am I actually incorporating that with everything else I know about the patient, and what am I going to do to treat the patient, as a separate piece in your MDM.

Scott: All right, Ray, any more thoughts, comments?

Ray: Yeah, one more. Now I want to charge. I've done my urodynamics. I want to charge the 26, and then I also want to charge an E/M. So to summarize what I would document: I'd put all that mumbo jumbo in one template that goes with every one of my cases. Then I would dictate for the 26 the findings and my impression. And then for my E/M, I would dictate what I'm going to do about it. Is that your take, Mark?

[13:00] Mark: Yes, it is. That's a pretty good summation. And apparently the word for the day is mumbo jumbo.

Ray: That beats the other word I was thinking.

Mark: It was.

Do records from another doctor in the same network count as MDM data?

Scott: That's very PG of you. All right, my turn. Enough of this mumbo jumbo, let's get on to the next question. This one came in from Jill, and Jill says: Good afternoon. I attended your seminar in New Orleans this year, and a couple of questions have come up from our doctors. If our doctor is reviewing labs, CT notes, et cetera, from another doctor that works in the same network, does that count as an MDM point? We'll take that one first, and then I'll ask the next one.

[14:00] Mark: Okay, so the short answer is, it depends. Obviously, one of the issues you've got to look at is, is that doctor in the network of the same specialty and part of the same practice? I'm assuming, the way the question is asked, the answer to that is no, and that this is coming from either another physician of the same specialty outside of their office but within their network, or, probably more likely, another specialty within the same network. I'm assuming this is a multi-specialty group, so we'll go with that as the general flavor of what this question is.

If that information comes in from a source outside of your practice, and that's really what we're looking for, not outside your network but outside of your practice pod, then that information is data. Now, the number of data points you get is actually the area that is, I think, a little bit more confusing. Let's say it came from a primary care physician in the network, and it comes in with the patient's full history, and within that report there are labs, CTs and other notes that are summarized within that physician's record. Then it's only one data point, even though you've got multiple pieces of information within it. CPT is pretty clear that a physician record is one data point and includes everything within that report, regardless of whether there are other data points within it.

Now, if you do a separate interpretation on a CT that was taken elsewhere, I would count that as a data point, even if somebody else used it for medical decision making or did their interpretation, because you are doing your own interpretation at that point in time. That's that extra work. If you got the report from the physician, and then maybe as part of the overall flow of the patient through the network the patient was instructed to get some additional tests, and those tests come to you separate from the record, then I would count those as separate data points in the review. So just remember, it's a package as it comes in, but anything that you identify that is outside of that package can be counted as a separate data point, even if your physician didn't order it.

[17:00] Scott: Let's tie it back to the last question, which is interesting, because what you're saying is this package comes in, and let's say you are doing your own interpretation of the CT. You're documenting those impressions and findings, right?

Mark: So you're not billing for the TC or the PC, the 26. But at this point in time you do want to put in your interpretation. Now, you don't have to have a separate report on this, because you're not billing that 26 modifier. But it's a good question. You still want to put in what you saw and what your conclusions are to support that you did that Category 2 interpretation. As we've talked about before: CT scan was viewed and interpreted, here are my findings. So your impression and your findings would be in that. In this case you're just doing the interpretation as part of MDM, so a separate finding based on that, I don't think you need to go to that level, as that's part of your MDM. But if you put it in there, it wouldn't hurt you. The most important part is you have to clearly include what you saw and what that indication was based on your interpretation. All right, Ray, thoughts, comments?

Ray: Well, the only thing I'll emphasize is one thing Mark said. We've always thought it would help clarify things if we changed the terminology so that when you look at a report, you've reviewed that report, but if you look at the actual CT scan, you viewed the CT scan. As Mark said, if you say "viewed," that doesn't leave any room for confusion, or it shouldn't leave any room for confusion.

Scott: Yes, and that's good. And you can always look back at your documentation, if you're consistent with that, and defend it.

Interpreters versus independent historians

Scott: All right. The second question was: if our doctor needs to use an outside interpreter for translation, does this count as a point?

Mark: Unfortunately, I can actually answer this question rather succinctly. No, it does not. The data point that we are given for history and medical decision making from another individual is not for an interpreter, but for an independent historian. The translator is simply providing the information that's provided by the patient in a way we can understand it. We can't count that as data. Unfair and unfortunate, but true. If, though, the patient actually can't communicate and you're asking someone else to provide that history, then that's an independent historian that could potentially be counted as a data point. Understand that it is one of those that's kind of buried in the guidelines, and it really only helps with some of the lower levels.

Scott: Ray, questions, comments?

Ray: Nothing to add.

Sponsors and final thoughts on payer scrutiny

Scott: Okay. 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/prs for specials for our listening audience. Also, we want to make sure you know that the PRS Coding and Reimbursement Hub is up and running and has information about specific categories like kidney stones and prostate biopsies, as well as individual products for those particular categories, and we're continuing to build out that platform. If you want to check out some of the categories and some of the products we have, we also have our PRS CodeMatrix guides and calculators. We're building more and more of these each week that you can use as a quick reference guide, and it gives you a summary, or, if you're using one of our calculators, you can calculate some of the ROIs or the revenue possibilities for different products and categories. If you want to check that out, you can go to prsnetwork.com/urologyhub. That'll get you started, and you can explore from there. All right, let's get some final thoughts. Final thoughts today, Mark.

Mark: Once again, I'll put the statement out there that it takes a village. We've got these payers at this point in time really tightening things up. This does seem to be a theme. The reaction across the board is the payers have the ability to analyze more, and they're putting more scrutiny on the medical records before they pay. And I did want to add that even though today we talked about this policy in reference to UnitedHealthcare, we actually saw a denial from Humana that asked for the same thing. So I don't think this is going to be isolated. It is one of those areas where, after a few reviews, this probably was driven by some of the downcodes for E/Ms. As they start looking at records and digging deeper and figuring out how they can look at records and monitor records, I think they're going to keep adding requirements for prepayment review. It may be that this is their ticket for getting the entire medical record before they pay any claim, which allows them to pull out additional diagnoses and deny different aspects of it.

So documentation, as we've been moving forward in this environment of artificial intelligence, is now becoming more and more important. It's important to understand your templates, to build your templates, and to understand how you interact with your electronic medical record, whether you're using an ambient scribe and all those things. You want to make sure that you've got things well lined up and you understand how that information reacts. Those tools are making our lives easier in many ways, but they do require supervision, because those tools need your support to make sure you're understanding where those targets are. So keep an eye on those things, and ultimately leverage all the tools you have available to you. They're tools, and we should leverage all of them appropriately in order to support what we're doing. And you do need some folks in your office who are quickly reviewing things to get them into the record so that you don't end up with more and more requests for medical records, or takebacks, or lookbacks. You've got to get your team in place. They need to be able to leverage all of their tools to respond to all these additional pressures that are out there. It's going to be a process internally to support your billing and to try to get you paid for everything that you do. I wish I had better news, but we've got to figure out the efficiencies on our side to leverage our resources in the best way possible to support the financial health of the practice.

Layers of rules: CPT, Medicare and payer contracts

[26:00] Scott: There certainly are a lot of rules out there, and since it is so complex, it's interesting to see what the payers are doing with those. Now that they have the ability, with AI and computer-assisted coding, they can really go down to the minutiae and pull out some of those rules that are available to them based on CPT or other rules or regs that have been made. That's tough, and it's just going to continue as far as we can see. It seems like it's becoming more and more detailed and complex.

[27:00] Mark: Yeah, Scott, I'll add on to that, and I know we're supposed to be on final thoughts. We had a discussion internally with Marianne, our COO of the revenue cycle arm, yesterday, and one of the things that is interesting as we go through this process is truly understanding how the layers of rules work. We've always talked about the fact that we've got CPT, and we do pull a lot of arguments and support from CPT, but we also have to remember that the interpretation of CPT is an interpretation. The reality is the payers layer rules on top of CPT that are only loosely supported by CPT, or in some cases in contrast with what CPT recommends. So we want to understand CPT and the rules that are there, and that's our basis. Then we have to layer on Medicare. But we also have to pay attention to each of our payer contracts, because those rules are really the payment rules. All the others serve as guidelines that the payers can adopt or not, and then we have to understand how they're going to enforce them. It is a complex system. The other thing I'll say is CPT sometimes has contradicting things in there, because it is a recommendation. It may have a guideline in one place, but the overarching guideline in the introduction may actually say go ahead and follow payer rules, even though they have specific rules tied to a specific code. So there's always an out in CPT, it seems, that some of the payers can rely on.

Scott: They use what they want and interpret it the way they want, and if they don't agree with it, they diverge. That's crazy. Ray, final thoughts?

Catching up with the payers' AI

[29:00] Ray: Well, I have a question for the two of you. As you do your education, figuring out how to get paid for new technology, and all the billing that you do, it would appear now that the payers' AI can outperform your AI. When are you going to catch up?

Mark: I'm going to go back to a concept that you introduced way back in the very beginning when we started all this stuff, and that's your initial golden rule: he who has the gold makes the rules. That's what you always instructed back when we started our first seminars in the 1990s. The rule makers are always ahead, which means the payers will always be ahead. We are playing the game of catch-up from day one, and we have to catch up as fast as we can. We have to monitor the bulletins and all the rules that are out there, and that's how we stay ahead. It just is the game as it is.

Scott: I'll add that it's kind of crazy that game has to be played when the ultimate goal of all of us is to get the patients the care they need. This administrivia, when it gets in the way, is frustrating to see, and we see that when working with a lot of device and pharma companies: the hoops they have to jump through to get their products to market. We do a lot of consulting on the reimbursement side of things, how to navigate the system, but the hurdles and the roadblocks that are up there from a reimbursement standpoint, there are a ton, and it's a shame to see this great technology being delayed because the reimbursement isn't there, and your practices suffer because you can't have those tools for your patients as quickly as you should. That's one of the problems we're trying to solve with all this as well. As the AI increases and the payers are making the rules, the patients are suffering, so we want to try to balance that out.

[32:00] Ray: Scott, I had one other comment. As we have stated many times before, this system in reality is not complicated. It is just detailed, and it's keeping up with the details. That all starts with the documentation for all of these rules. So be sure you're documenting for clinical as you always have, but be sure you're doing the reimbursement documentation as well.

Scott: Yep, so true. And as Mark said earlier, it takes a village. It takes us all. So, as the urology community, let's do what we can to get those patients the care they need and make this reimbursement go a little more smoothly. Sharing that information is key. Knowledge is the key. That's all we have for today. Thank you all for listening. Take us out, Ray.

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