Key takeaways from this episode

• A floor consult that ends in a PCNL supports an E/M with modifier 57. PCNL carries a 90-day global, and Medicare excludes the decision for major surgery from the global package.
• If the decision is a stent (52332) or ureteroscopic stone treatment, the E/M needs modifier 25 and documentation of a separate workup. Those are zero-day globals that include the pre-procedure visit, so the note must show you reviewed the history and imaging and made the diagnosis, not just prepped the patient for the scope.
• "Seen on the floor" does not automatically mean 99222. Pick the E/M category by the patient's status and location: office or other outpatient, emergency department, or inpatient.
• Humana's position that 55869 requires removal of all three node groups is not supported by CPT. CPT never defines "including," and the people who developed 55869 did not intend it to require the external iliac, hypogastric and obturator groups in every case; the AUA/ASCO/ASTRO/SUO bladder cancer guideline (revised 2020 and 2024) is the best available clinical definition of a bilateral pelvic lymphadenectomy.
• Code by what was performed: 55869 for a true bilateral pelvic lymphadenectomy, 55868 for limited sampling. If the dissection was intended but only partially completed for a documented medical reason, stay on 55869 and let the op note decide between modifier 22 (extra effort) and modifier 52 (reduced service); if you pivoted to biopsy only, drop to 55868.
• Appeal on medical necessity with primary sources, and check the payer's own policy. AI-generated denials read "including" literally, so cite CPT and CMS first and specialty guidelines second; if Humana has published a written policy requiring all three groups, your contract may bind you to it.
• Bladder stone removal through the same incision as a laparoscopic simple prostatectomy (55867) is reported with unlisted code 51999. 55867 does not include entering the bladder, and 52317 and 52318 are transurethral codes, so approach rules them out.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 298, recorded July 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

A floor consult for a ureteral stone that leads to the OR

[00:00] Scott Painter: On this episode: E/M coding for a floor consult with an OR decision. Also, bilateral pelvic lymphadenectomy denials. Finally, same-incision simple prostatectomy with bladder stone removal. How do you code it? Stay tuned. Welcome to episode 298 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 cover a few questions, so let's dive right in. I'm going to read the question for you, Mark, and see what you think. First question: I am consulted to see a patient on the floor. They have a ureteral stone, and I make the decision to take them to the OR. Am I able to bill an initial encounter E/M code on the same day as a stone procedure or stent insertion? What have you got, Mark?

[01:05] Mark Painter: As usual, we're going to start with "it depends," because it always depends on exactly what the circumstance is. I'm assuming, number one, that you did go see the patient on the floor. You evaluated the patient, you looked through the patient's history and their imaging, made the diagnosis of a stone, and decided at that point that it was appropriate to take the patient to the OR. And in this question, the choice was a stone procedure or a stent insertion.

So we've got a couple of choices for stone procedures. If the decision was to go for a PCNL to treat the stone, that's a 90-day global procedure. I think that's an easy one with a 57 modifier, because the decision for surgery is not included in a major surgery, a surgery with a 90-day global, under Medicare's guidelines. That fits, and that may work for some private payers too, depending on how they handle the definition. Unfortunately, the insertion of a stent, 52332, or treatment of the stone through a scope, those are all zero-day globals. According to Medicare globals, the visit immediately prior to surgery and prepping for surgery is included. So we have to go to what is not included, and that would be a significant or separately identifiable evaluation and management service.

So the fact that you were consulted on the patient, and this is where the "depends" comes in, and you were the one who actually made the final diagnosis of a stone that needed to be treated that day, you could look at that as a significant and separate evaluation. The wording in the global is that if you're just working them up to go to surgery, that really wouldn't be a separately billable visit with your zero- or ten-day global procedures. That's where the note comes into play. Was this something where you actually had to review the information because the patient had flank pain, a suspected stone, or a stone that could be managed in a bunch of different ways? They weren't referred to you to basically perform a procedure through a ureteroscope, or a cystoscope in the case of the stent insertion. Then you've got the argument for modifier 25. And with the PCNL, you've got the decision for surgery.

I think in both cases the question is leading to say, "I did make the decision for surgery." So I'm going to assume the answer is going to be yes, but for the zero-day globals, that documentation had better support that you did the separate medical decision-making and evaluation, which included the decision for surgery, rather than a quick workup to take him to surgery.

[05:01] Scott: Ray, thoughts, comments?

[05:05] Dr. Ray Painter: Sounds good.

[05:07] Scott: And if you're in the hospital, that would be the 99222.

[05:11] Mark: Actually, we don't know where they are. They're seen on the floor. That could be a standard office or other outpatient visit. It could be an emergency department visit. It could be an inpatient visit. It depends on what status the patient is in and where they're located.

[05:33] Scott: Yeah, I guess "seen on the floor" is a little broad.

[05:37] Mark: That's fair.

A Humana denial for bilateral pelvic lymphadenectomy with 55869

[05:40] Scott: Let's move on to the next one. This question came in during our webinar on E/M and AI ambient listening scribes, which you can access if you want to listen to that discussion. It was a very interesting discussion, and Mark walked us through some of the things you need to consider if you have an AI scribe and are using AI to do your documentation. If you want to check that out, go to prsnetwork.com and find the monthly webinar recordings. This question says: "My provider performed a laparoscopic prostatectomy with bilateral pelvic lymphadenectomy, and Humana denies the claim and states that we need to remove all three lymph nodes: the external iliac, the hypogastric and the obturator." Mark, is that true?

[06:57] Mark: I tell you, this is one of those issues that has a lot of opinions and no true concrete answer, unfortunately. But I'm going to lean on a couple of different things to say absolutely that is not true, and there are a couple of ways to appeal it. Without a definitive answer, that's going to be one of those difficult things we have to navigate, and we're talking about medical necessity and a few other things.

First, let's look at our options. We essentially have two codes for robotic prostatectomies with lymph nodes now, and those are both new codes. We've got the 55868, which is laparoscopy, surgical prostatectomy, retropubic radical, including nerve-sparing, includes robotic assistance when performed, with lymph node sampling, and the parenthetical is limited lymphadenectomy. Then you have the 55869, which is laparoscopy, surgical prostatectomy, retropubic radical, including nerve-sparing, includes robotic assistance when performed, with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes.

I think that's where the payer is hanging things, on that "including." Now, we could explore the definition of "including" in this single code. One would be "including nerve-sparing." If you didn't do the nerve-sparing for the procedure, would it get denied for that? Probably not. That's extra work that's there. They clearly aren't going to allow you to bill for it separately under a different procedure, which we don't really have a code for anyway. Then it "includes robotic assistance when performed." So there's another use of the word "includes" or "including," with the modifying verbiage "when performed," indicating you could do this with or without a robot and it doesn't change the code. That one's a little clearer. Then we've got "with bilateral pelvic lymphadenectomy." That essentially locks in that a bilateral pelvic lymphadenectomy needs to be done. The part left is the "including external iliac, hypogastric and obturator nodes." Again, we know we can't bill for this separately. It doesn't say "when performed," so we don't have that same variability. That does make it a little difficult, and this is where I think the payers are pushing back.

But overall, "including" is used sixteen hundred times, "includes" is used eight hundred and eighty times, and "include" is used four hundred and forty-one times. So we've got some variation of "includes" distributed throughout the CPT book, with actually nothing in CPT that gives us a real definition of what "including" means. Does it mean it can't be billed elsewhere? I think that's true. But does it mean you have to do everything in the includes, including or include list? That's where I have a beef with all this. My interpretation is that the real procedure is bilateral pelvic lymphadenectomy. That's what needs to be performed, or at least most of it, before we move off that code, because our step down is with lymph node biopsies, or the limited pelvic lymphadenectomy. Those are the two choices we have, because the coding convention within CPT is that you pick the most accurate code, and if it needs to be modified, it needs to be modified.

The second piece I would refer to is: what does my specialty society say? According to the guideline on treatment of non-metastatic muscle-invasive bladder cancer, which is the AUA, ASCO, ASTRO and SUO guideline, revised in 2020 and then again in 2024, the definition is that when performing a bilateral pelvic lymphadenectomy, clinicians should remove at a minimum the external and internal iliac and obturator lymph nodes. That's what it says at this point in time. Now, are we in the right space? That wasn't about the prostate. But it is a fairly strong definition of a pelvic lymphadenectomy, the best we could find. These are the things we try to look at: clinically, what really is a bilateral pelvic lymphadenectomy? Because that's the true procedure being performed.

The "includes" I would consider more or less a guideline of what should be part of the bilateral pelvic lymphadenectomy, because in fact, most of the time there are more nodes taken than just three. It's a series of nodes within tissue in those areas, groups of nodes, not just a node here or there. So I would argue on the medical necessity side as to what the appropriate node dissection is, and clearly document what was removed in that area as a full lymphadenectomy, not as sampling. If you're taking a node here or a node there, biopsy-wise, then you've got to drop to the 55868. If you couldn't perform the intended, medically necessary number of nodes you wanted to remove, that's a modifier. It could be a 52, could be a 22, depending on whether it was more or less work during that particular encounter. So the documentation in that note should really focus on the medical necessity of what you did, and on the fact that it was a bilateral pelvic lymphadenectomy following guidelines for the treatment of, we would assume in this case, prostate cancer. Ray, comments, questions?

Intent, partial dissection, and modifiers 22 and 52

[14:52] Ray: Mark, I think that was an excellent explanation. Even I understood it. The question I have is: how does intent fall into this? I went in intending to do a complete pelvic lymphadenectomy, and I took nodes out of a couple of those areas, or all three, on one side, and I could only get one, maybe two, on the other side. Do I still qualify for the full lymphadenectomy? Because that's still a lot more work, the intent was there, and I truly documented that I didn't go in and just do a biopsy on each side.

[15:51] Mark: As we've seen through a lot of this, intent is definitely one thing to be considered. And the reason you could not complete it, or the election during the procedure to perform a lesser procedure because of what you found, doesn't always reflect intent. Ultimately, if you went in there and for whatever reason the decision was, "We're not going to do the bilateral pelvic lymphadenectomy, we're going to pivot and simply do limited node sampling for this particular patient," then you'd have to drop down to the 55868. There is a procedure code that describes what you did. If you got in there and you were able to do one side of the bilateral pelvic lymphadenectomy but not the other because of some medically necessary reason, and you explain that in the operative note, then I think you are closer to the 55869 than the 55868, because of what you were attempting to do but surgically could not, and you elected not to do it based on the medical necessity of that patient during that operation. So yes, intent is a big piece of it, but in the end it's more about why you didn't do what you intended to do. Medical necessity should be the driving force, and you want to back it as much as you can with guidelines and opinions from respected sources.

[17:51] Scott: Would you append a 52 modifier on the 69, or would you just drop back to the 68?

[18:00] Mark: If you only did one side? The 55869.

[18:02] Scott: Yeah.

[18:04] Mark: I don't know what I would do. It would depend on why I didn't do the other side. I would look at it from the standpoint of, if I was trying to do it and I couldn't get there, then I might use a 22 even though I didn't do the full bilateral pelvic, because it was extra effort to do what I did and I was most of the way there. I was closer to a bilateral pelvic lymphadenectomy than simply sampling. In the end, that's where Ray brought in the question of intent, but that's where it shows that the effort was made to do the bilateral pelvic lymphadenectomy, through the effort described in the operative note and what it supported. That's what I'd look for. Again, I'd have to read the operative note to be sure how I'd recommend it. But based on what you're giving me, it sounds like maybe I would use the 55869, and I would look at the op note to see whether it's a 52 or a 22. Ray, any other comments?

[19:13] Ray: That was very good. The only thing I would say is the other side of that intent note, if I understand it, Mark: if I intended to do a radical with bilateral lymphadenectomy, and I got in there and saw everything was so stuck down that I made the decision to just do a biopsy on both sides, then I would have to drop down to the other one. Because it does say in there somewhere that you have to charge for the procedure you did. But if my documentation shows I tried, I attempted, and I partially accomplished the job, you're right, I would stick with the 69.

AI-driven denials and the value of primary sources

[20:01] Scott: Last question on this. This specifically stated Humana. Mark, are you seeing any of these denials coming from others for this specific denial?

[20:13] Mark: I'm going to say on occasion we've seen things. I think this is an area where we're starting to see AI push a black-and-white answer into a gray area. The interpretation of "including": you can put this into any AI and it can give you a definitive answer based on somebody's opinion from the internet, as if "including" means you have to have all three, and we did that. But you can also ask additional questions of your AI tool and say, "What did you base this on? Is that a definitive source? Give me an answer from CPT or CMS," and you won't get one. The AI will say, "Well, that's a fair point," and it'll give you some other wishy-washy answer. But it'll come out of the gate swinging with black or white based on what it reads off the page, and I think that's as far as Humana went, or whoever was running that particular inquest on that note.

[21:26] Scott: It's a very valid point. You always quote and preach primary sources versus secondary sources, and you're always very adamant that you back it up with a primary source. I think that's good advice. And then you can argue medical necessity and those things with an AUA source. That's not a rulemaking body, as you've said many a time, but it certainly is a clinical guidance body. That's the medical necessity side of things.

[22:08] Mark: I would say it's a primary source one step away. They're part of the development of the code set, so they understand, and this is another one where we're bringing in the intent of the code. The CPT code nomenclature and structure is a decent system, a very good system for a lot of things, and we leverage it for everything we do, but it is by no means all-inclusive or perfect. As you can see by the two definitions, there's a gap in clinical procedure between lymph node sampling and bilateral pelvic lymphadenectomy, and you pick the code to report your services because it covers the majority of what you did with the laparoscopic prostatectomy and nodes. It's probably not worth going to unlisted, but you've definitely got a little bit of, boy, does this need a modifier? Does it not? Should it just be coded without a modifier? Those questions don't have hard answers. I remember talking to a couple of folks who were part of the process of developing the 55869, and it was never intended to say that if you didn't take all three of those listed node groups, you shouldn't bill the 55869, or that you needed a modifier. So I've heard it at all scales, and of course we all know we have multiple rulemakers out there doing the interpretation. Now we've got AI, so we've got many more multiples of rulemakers, and whatever opinion is closest for the AI to pull in, that's what it's going to pull.

[24:08] Scott: And the difference in payment for the 55869 and 55868 is not a nominal amount either.

[24:16] Mark: It's not. It's a few hundred bucks, and it's mostly in work RVUs. So that's a bigger differential when you're getting paid on work RVUs than if you're just getting the full revenue stream. That's where that sits.

Bladder stone removal during a laparoscopic simple prostatectomy

[24:38] Scott: Let's move on to our final question. Again, this came in from one of our attendees at our webinar. The question was: billing a laparoscopic simple prostatectomy, the 55867, with bladder stone removal from the same incision. How do you bill that?

[25:02] Mark: We know the 55867 is the simple subtotal laparoscopic surgical prostatectomy, which includes the vasectomy, meatotomy, urethral calibration and dilation, and internal urethrotomy. So nothing about the stones, nothing about actually entering the bladder, which I'm assuming is what we're talking about here, that they're laparoscopically going into the bladder to remove the stone. We don't see that as an inclusion in the 55867. So now we look at whether there are any laparoscopic bladder stone removal codes. There are not many laparoscopic bladder codes to look at, and ultimately neither of the two available procedure-specific codes has bladder stone treatment in it. So in this case, I think you're going to bill a 51999, unlisted laparoscopic bladder procedure, for the bladder treatment performed at the same time as the laparoscopic simple prostatectomy. Ray, questions or comments?

[26:34] Ray: Well, Mark, there is a lithotripsy code, so why can't you use it?

[26:42] Mark: Unfortunately, the 52317 and the 52318 are transurethral surgeries. They're in the transurethral section, and even though they don't actually say cystourethroscopy, we would look at those, within that section, as transurethral surgery, and we didn't go transurethral. As we know, and have been told multiple times, laparoscopic, robotic, all those things, approach matters. That's why we have to use unlisted codes for a laparoscopic cystectomy instead of a straight open cystectomy code. It's location, kind of like real estate.

Sponsors and final thoughts

[27:24] Scott: All right, let's wrap this episode up. 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. We'd also like to thank UroGen, manufacturers of Zusduri and Jelmyto. For more information, you can go to zusduri.com or jelmyto.com. Let's get some final thoughts. Mark, final thoughts today?

[27:58] Mark: Today was really a rule- and CPT-based discussion: interpretation of language, looking at medical necessity, and leveraging all the tools that are out there, because there is and will remain a significant amount of gray in this overall process of correctly reporting all the services provided for your patients. I would say don't get stuck in the quagmire of the exact phrasing, but don't ignore it either. Look at the intent of the code, look at how we can leverage medical necessity and different guidelines across the board to determine the best answer for your case if it doesn't follow the line that puts you in the right direction.

Then, of course, you've got the secondary piece we always mention, which is that CPT isn't the only rule set. Layered on top of that are CMS and the payers and their interpretations. Making sure you understand where the folks that have the money fall on those interpretations is going to make a difference. Even with our discussion on the 55868 and 69, we gave you the CPT rules. If Humana published a guideline that said 55869 has to include all three of these, otherwise you have to use 55868, then you're kind of stuck, because of the contract in which you agreed to follow their guidelines. So pay attention to all of it, as always. There are layers, kind of like a parfait.

[29:51] Scott: Can't imagine what's in that parfait.

[29:53] Mark: I wouldn't want to eat that parfait, but everybody likes parfait.

[29:57] Scott: All right, Ray, final thoughts?

[30:00] Ray: Well, it all boils down to intent, documentation, and what was actually done. And as Mark says, don't get lost in the weeds, because you want to know exactly what you want to charge. I hope everybody appreciates the depth of research and the argument within himself, yes I can, no I can't, et cetera, that Mark goes through in coming up with these answers. So, thanks.

[30:45] Scott: When we prepare for these podcasts, oftentimes we spend hours discussing the various options and what goes on, and we do the research and spend a lot of time. Today's episode was a culmination of discussion and research. I want to remind you that the Urology Advanced Coding and Reimbursement Seminar registration is open. If you go to prsnetwork.com, right there on the homepage is a seminar registration button. These are the kind of in-depth discussions we have at the Urology Advanced Coding and Reimbursement Seminar. There is always something happening and always something new, and learning from others who are going through this is so important. Through our podcast and webinar we try to bring you this information, but there's nothing like being immersed in these topics and questions with like-minded people for two days, where you get so much more out of it. We encourage you to join us. It is well worth the time and investment.

I also want to remind you that the PRS Coding and Reimbursement Hub, available at prsnetwork.com/urologyhub, has a lot of information, and we are adding more and updating that information each week. So keep that in mind. If you're looking at your AI for the right information, we've spent a lot of time vetting this information, so you can point your AI at our hub for some of the resources. We encourage you to do that. That's all we have for today. We want to thank you all for listening. Take us out, Ray.

Ray: Happy coding and billing.

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