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    Reimbursement

    This information is provided by Laborie for reimbursement informational purposes only. This is not an affirmative instruction as to which codes and modifiers to use for a particular service or item. Any coding, coverage, and payment information contained herein is gathered from various resources and is subject to change without notice. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Laborie recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

    MKT-00792 [C]

    Urodynamics

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1     		Description 20252
    51726 Complex Cystometrogram (i.e, calibrated electronic Equipment) $269.12
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51798 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging  $11.32
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51728 Complex cystometrogram (ie, calibrated electronic equipment) with voiding pressure studies (ie, bladder voiding pressure), any technique $328.64 
    51741-51 Complex uroflowmetry (eg, calibrated electronic equipment) $6.96 
    51784-51 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique $31.06 
    +51797* Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) $161.09 
    * Code +51797 can only be billed if also billing either 51728 or 51729. +51797 is not billed with a -51 modifier as it is an add-on code to 51728 or 51729.
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51729 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique $348.05 
    51741-51 Complex uroflowmetry (eg, calibrated electronic equipment) $ 6.96
    51784-51 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique $31.06
    +51797* Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) $161.09 

    * Code +51797 can only be billed if also billing either 51728 or 51729. +51797 is not billed with a -51 modifier as it is an add-on code to 51728 or 51729.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51729 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique $348.05 
    51741-51 Complex uroflowmetry (eg, calibrated electronic equipment) $6.96 
    51784-51 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique $31.06
    +51797* Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) $161.09 
    51600 Injection procedure for cystography or voiding urethrocystography $98.98 
    74455 Urethrocystography, voiding, radiological supervision and interpretation $98.33 

    * Code +51797 can only be billed if also billing either 51728 or 51729. +51797 is not billed with a -51 modifier as it is an add-on code to 51728 or 51729.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51728 Complex cystometrogram (ie, calibrated electronic equipment) with voiding pressure studies (ie, bladder voiding pressure), any technique $328.64
    51741-51 Complex uroflowmetry (eg, calibrated electronic equipment) $6.96 
    51784-51 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique $31.06 
    +51797* Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) $161.09
    51600 Injection procedure for cystography or voiding urethrocystography $98.98 
    74455 Urethrocystography, voiding, radiological supervision and interpretation $98.33 

    * Code +51797 can only be billed if also billing either 51728 or 51729. +51797 is not billed with a -51 modifier as it is an add-on code to 51728 or 51729.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    91120 Rectal sensation, tone, and compliance test (ie, response to graded balloon distention) $463.20 
    91122 Anorectal manometry $264.27 
    51784-51 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique $31.06 
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    Optilume®

    The following tables provide CPT coding for the Optilume procedure and 2025 Medicare National Average Payment for the physician, hospital outpatient, and ambulatory surgery center (ASC) settings of care. Payment will vary by geographic location. Private payors will pay based on contracted rates.



    		 2025 Medicare National Average Payment
    CPT™
    Code1    		 Description Physician
    Facility    2
    		 Physician
    Non-Facility2    		 Hospital
    Outpatient3    		 Ambulatory
    Surgery Center4
    52284 Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed. $158.82 $2,466.74 $5,083.62 $3,315.70
    HCPCS Code5 Description Revenue Code6
    FOR HOSPITAL OUTPATIENT ONLY – REPORT C1889 WITH MEDICARE FEE FOR SERVICE (FFS) CLAIMS, NOT WITH MEDICARE ADVANTAGE OR PRIVATE PAYER CLAIMS.
    C1889 Implantable/insertable device, not otherwise classified 0278-MEDICAL/SURGICAL SUPPLIES AND DEVICES

     

    Reimbursement Consideration

    • Do not report CPT code 52284 with CPT code 52281 or 52283.
    • When setting Medicare payment for CPT code 52284, the Centers for Medicare & Medicaid Service (CMS) does not consider the expense of the Optilume® device because the hospital claims data CMS uses is not capturing that expense.
    • CMS relies on hospital claims data and in order for CMS to be able to identify the expense for the Optilume device, hospital claims need to include a Healthcare Common Procedure Coding System (HCPCS) code and appropriate charge for the device, in addition to CPT code 52284 for the procedure.
    • Because there is currently no unique (HCPCS) code to describe the Optilume device, the most appropriate code to report for the device is C1889 (Implantable/insertable device, not otherwise classified).
    • Thus, reporting HCPCS code C1889 and an appropriate charge for the device, together with CPT code 52284, on claims for the Optilume procedure will help CMS determine a more appropriate payment level for the service.

    Do not report 52284 in conjunction with 51610, 52000, 52281, 52283, 74450 or 76000.

    For coding, coverage or reimbursement assistance, please reach out to the Health Policy and Reimbursement Team at reimbursement@laborie.com.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
    2. 2. CMS 2025 Physician Fee Schedule. Addendum B. Effective through December 31, 2025.
    3. 3. CMS 2025 Hospital Outpatient Fee Schedule. Addendum B. Effective through December 31, 2025.
    4. 4. CMS 2025 Ambulatory Surgery Center Fee Schedule. Addendum AA. Effective through December 31, 2025.
    5. 5. CMS 2025 Healthcare Common Procedure Coding System (HCPCS Level II). Effective through December 31, 2025.
    6. 6. 2025 Revenue Code. National Uniform Billing Committee (NUBC™). American Hospital Association.

    Disclaimer
    The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee concerning levels of reimbursement, payment, or charge. Similarly, CPT® codes supplied are for
    informational purposes only and represent no statement, promise, or guarantee by the company that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer.
    We strongly recommend that you consult your payer organization with regard to its reimbursement policies.

    The following tables provide CPT coding for the Optilume procedure and 2025 Medicare National Average Payment for the physician, hospital outpatient, and ambulatory surgery center (ASC) settings of care. Payment will vary by geographic location. Private payors will pay based on contracted rates.



    		 2025 Medicare National Average Payment
    CPT™
    Code1    		 Description Physician
    Facility    2
    		 Hospital
    Outpatient3    		 Ambulatory
    Surgery Center4
    0619T Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed. Carrier Priced* $9,247.15 $6,428.02
    HCPCS Code5 Description Revenue Code6
    FOR HOSPITAL OUTPATIENT ONLY – REPORT C1889 WITH MEDICARE FEE FOR SERVICE (FFS) CLAIMS, NOT WITH MEDICARE ADVANTAGE OR PRIVATE PAYER CLAIMS.
    C1889 Implantable/insertable device, not otherwise classified 0278-MEDICAL/SURGICAL SUPPLIES AND DEVICES
    ICD-10 Code Description
    N40 Benign Prostatic Hyperplasia (BPH)
    Secondary or Tertiary
    ICD-10 Codes    		 Description
    N40.0 BPH without lower urinary tract symptoms
    N40.1 BPH with lower urinary tract symptoms
    N40.2 Nodular prostate without lower urinary tract symptoms
    N40.3 Nodular prostate with lower urinary tract symptoms

     

    Reimbursement Consideration

    • When setting Medicare payment for CPT code 0619T, the Centers for Medicare & Medicaid Service (CMS) does not consider the expense of the Optilume device because the hospital claims data CMS uses is not capturing that expense.
    • CMS relies on hospital claims data and in order for CMS to be able to identify the expense for the Optilume® device, hospital claims need to include a Healthcare Common Procedure Coding System (HCPCS) code and appropriate charge for the device, in addition to CPT code 0619T for the procedure.
    • Because there is currently no unique (HCPCS) code to describe the Optilume device, the most appropriate code to report for the device is C1889 (Implantable/insertable device, not otherwise classified).
    • Thus, reporting HCPCS code C1889 and an appropriate charge for the device, together with CPT code 0619T, on claims for the Optilume procedure will help CMS determine a more appropriate payment level for the service.

    For coding, coverage or reimbursement assistance, please reach out to the Health Policy and Reimbursement Team at reimbursement@laborie.com.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
    2. 2. CMS 2025 Physician Fee Schedule. Addendum B. Effective through December 31, 2025.
    3. 3. CMS 2025 Hospital Outpatient Fee Schedule. Addendum B. Effective through December 31, 2025.
    4. 4. CMS 2025 Ambulatory Surgery Center Fee Schedule. Addendum AA. Effective through December 31, 2025.
    5. 5. CMS 2025 Healthcare Common Procedure Coding System (HCPCS Level II). Effective through December 31, 2025.
    6. 6. 2025 Revenue Code. National Uniform Billing Committee (NUBC™). American Hospital Association.

    Disclaimer
    The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee concerning levels of reimbursement, payment, or charge. Similarly, CPT® codes supplied are for informational purposes only and represent no statement, promise, or guarantee by the company that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payor. We strongly recommend that you consult your payor organization with regard to its reimbursement policies.

    Eclipse™ System for Bowel Control

    Possible Coding for Physician, Hospital Outpatient and Ambulatory Surgical Center (ASC)
    The following tables provide Current Procedural Technology (CPT)1 codes, Healthcare Common Procedure Coding System (HCPCS)2 code and 2025 Medicare National Average Payment.

    Evaluation and Management CPT codes (w/-25 Modifier)*

    New Patient 99201-992051 Office/outpatient visit, new patient 15-60 minutes
    Existing Patient 99211-992151 Office/outpatient visit established patient through 40 minutes
    Insertion of Eclipse Device 571601 Fitting and insertion of pessary or other intravaginal support device

     

    Eclipse™ HCPCS Code and 2025 Medicare DMEPOS Reimbursement
    Eclipse™ is reimbursed under Medicare Part B. Payment will vary by geographic location.

    HCPCS1 Code  Description 2025 Medicare National Average Payment2
    A4563 Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each. $1,634.74 

    *Review all key components listed for each E/M code and determine the most appropriate code, if any, for the visit based on the documented requirements from the AMA. The -25 modifier may be added to the E/M service to designate the fitting procedure was separate and distinct from the E/M services. A separate procedure note for the fitting is required and typically assigned to the diagnosis code describing the reason for the fitting.

    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
    2. 2. CMS 2025 Healthcare Common Procedure Coding System (HCPCS) Level II.

    Urgent PC Percutaneous Posterior Tibial Nerve Stimulation (PTNS)

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming $109.65 
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

    Urethral Bulking

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    51715 Endoscopic injection of implant material into the submucosal tissues of the urethra and / or bladder neck $340.29
    L86063 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies $258.42 
    L8606x5 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies *This product comes from Laborie in 2.5 ml Syringes only. HCPCS Code L8606 is coded in 1 ml units. Total per procedure would be 5 units total. $1292.10
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.
    2. 3. CMS 2025 Healthcare Common Procedure Coding System (HCPCS) Level II.

     

    Cystoscopy

    2025 Uro CPT Codes and Medicare National Average Allowable Payment

    CPT™
    Code1    		 Description 20252
    52000 Cystourethoscopy (separate procedure) $213.16 
    52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple $292.41
    52204 Cystourethroscopy, with biopsy(s) $ 343.20
    52287 Cystourethroscopy, with injection(s) for chemodenervation of the bladder $354.84
    1. 1. CPT codes, descriptions and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components aren’t assigned by the AMA, aren’t part of CPT, and the AMA isn’t recommending their use. The AMA doesn’t directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
      2. CMS 2025 Physician Fee Schedule. Effective through December 31, 2025.

     

     

    Possible ICD-10 Diagnosis codes

    CODE5 DESCRIPTION
    N32.3 Diverticulum of bladder / Diverticulitis of bladder
    N32.81 Overactive bladder
    N35 Urethral stricture
    N36.1 Urethral diverticulum
    N36.4 Urethral functional and muscular disorders
    N36.42 Intrinsic sphincter deficiency (ISD)
    N36.44 Muscular disorders of urethra
    N39.0 Urinary tract infection, site not specified
    N39.3 Stress incontinence; use additional code to identify overactive bladder or detrusor muscle hyperactivity
    N39.41 Urge incontinence
    N39.44 Nocturnal enuresis
    N39.46 Mixed incontinence
    N40.1 Enlarged prostate with lower urinary tract symptoms (LUTS)
    R33 Retention of urine
    R35 Polyuria, Frequency of micturition, Nocturia
    R35.0 Urinary frequency
    R35.1 Nocturia
    R39.11 Hesitancy of micturition
    R39.12 Poor urinary stream
    R39.14 Feeling of incomplete bladder emptying
    R39.15 Urgency of urination
    R39.16 Straining to void
    R39.81 Functional urinary incontinence
    K59 Other functional intestinal disorders
    K59.0 Constipation
    K59.1 Functional diarrhea
    K59.2 Neurogenic bowel, not elsewhere classified
    K59.3 Megacolon, not elsewhere classified
    K59.8 Other specified functional intestinal disorders
    K59.9 Functional intestinal disorder, unspecified
    K60 Fissure and fistula of anal and rectal regions
    K62.9 Disease of anus and rectum, unspecified
    K59 Other functional intestinal disorders
    1. 5.https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm

    Possible GI ICD-10 Diagnosis codes

    CODE5 DESCRIPTION
    K21.0 Gastro-esophageal reflux disease with esophagitis
    K21.9 Gastro-esophageal reflux disease without esophagitis
    K22.0 Achalasia of cardia
    K30 Functional dyspepsia
    K52.2 Allergic and dietetic gastroenteritis and colitis
    K52.89 Other specified noninfective gastroenteritis and colitis
    R11.0 Nausea
    R11.10 Vomiting, unspecified
    R11.11 Vomiting without nausea
    R11.12 Projectile vomiting
    R11.13 Vomiting of fecal matter
    R11.14 Bilious vomiting
    R11.2 Nausea with vomiting, unspecified
    R12 Heartburn
    R13.0 Aphagia
    R13.10 Dysphagia, unspecified
    R13.11 Dysphagia, oral phase
    R13.12 Dysphagia, oropharyngeal phase
    R13.13 Dysphagia, pharyngeal phase
    R13.14 Dysphagia, pharyngoesophageal phase
    R13.19 Other dysphagia
    R14.0 Abdominal distension (gaseous)
    R14.1 Gas pain
    R14.2 Eructation
    R14.3 Flatulence
    R15.0 Incomplete defecation
    R15.1 Fecal smearing
    R15.2 Fecal urgency
    R15.9 Full incontinence of feces
    R19.11 Absent bowel sounds
    R19.12 Hyperactive bowel sounds
    R19.15 Other abnormal bowel sounds
    R19.2 Visible peristalsis
    R19.4 Change in bowel habit
    R19.5 Other fecal abnormalities
    R19.7 Diarrhea, unspecified
    R19.8 Other specified symptoms and signs
    1. 5.https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm

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