Understanding Healthcare Reimbursement

Urodynamics

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
51726	Complex Uroflowmetry ( eg, calibrated electronic Equipment)	$ 13.55

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
51798	Meausurement of post-voiding residual urine and or bladder capacity by ulrasound, non imaging	$ 10.24

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
51728	Complex cystometrogram (ie, calibrated electronic equipment) with voiding pressure studies (ie, bladder voiding pressure), any technique	$ 366.30
51741-51	Complex uroflowmetry (eg, calibrated electronic equipment)	$ 6.77
51784-51	Electromyography studies (EMG) of anal or uretral sphincter, other than needle, any technique	$31.40
51797*	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List seperately in addition to code for primary procedure)	$195.71
	Total	$600.18

* 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. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
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	$ 387.13
51741-51	Complex uroflowmetry (eg, calibrated electronic equipment)	$ 6.77
51784-51	Electromyography studies (EMG) of anal or uretral sphincter, other than needle, any technique	$31.40
51797*	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List seperately in addition to code for primary procedure)	$195.71
	Total	$621.01

* 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. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
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	$ 387.13
51741-51	Complex uroflowmetry (eg, calibrated electronic equipment)	$ 6.77
51784-51	Electromyography studies (EMG) of anal or uretral sphincter, other than needle, any technique	$31.40
51797*	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List seperately in addition to code for primary procedure)	$195.71
51600	Injection procedure for cystography or voiding urethrocystography	$215.88
74455	Urethrocystography, voiding, radiological supervision and interpratation	$105.13
	Total	$942.02

* 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. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
51728	Complex cystometrogram (ie, calibrated electronic equipment) with voiding pressure studies (ie, bladder voiding pressure), any technique	$ 366.30
51741-51	Complex uroflowmetry (eg, calibrated electronic equipment)	$ 6.77
51784-51	Electromyography studies (EMG) of anal or uretral sphincter, other than needle, any technique	$31.40
51797*	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List seperately in addition to code for primary procedure)	$195.71
51600	Injection procedure for cystography or voiding urethrocystography	$215.88
74455	Urethrocystography, voiding, radiological supervision and interpratation	$105.13
	Total	$921.19

* 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. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
91120	Rectal sensation, tone, and compliance test (ie, response to graded balloon distention)	$ 524.99
91122	Anorectal manometry	$ 278.55
51784-51	Electromyography studies (EMG) of anal or uretral sphincter, other than needle, any technique	$31.40

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

Optilume® Urethral Drug Coated Balloon

The following tables provide CPT coding for the Optilume procedure and 2023 Medicare national average reimbursement for the physician, hospital outpatient, and ambulatory surgery center (ASC) settings of care. Payment will vary by geographic location. Private payers will pay based on contracted rates.

		2023 Medicare National Average Payment
CPT™ Code¹	Description	Physician Facility²	Hospital Outpatient³	Ambulatory Surgery Center⁴
0499T	Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed	Carrier Priced*	$3,205.12	$1,496.56

Do not report 0499T in conjunction with 52281 or 52283.

*For most carrier-priced procedures, each Medicare Administrative (MAC) uses individual consideration when reviewing a carrier-priced procedure and may request medical records to assist in the evaluation and pricing. This occurs only after receipt of the claim. Therefore, providers who submit claims electronically should indicate that documentation is available upon request.

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.
3. CMS 2023 Hospital Outpatient Fee Schedule. Addendum B. Effective through December 31, 2023.
4. CMS 2023 Ambulatory Surgery Center Fee Schedule. Addendum B. Effective through December 31, 2023.

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 2023 Medicare National Average Payment.

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

New Patient	99201-99205¹	Office/outpatient visit, new patient 10-60 minutes
Existing Patient	99211-99215¹	Office/outpatient visit established patient 5-40 minutes

Eclipse™ HCPCS Code and 2023 Medicare DMEPOS Reimbursement
Eclipse™ is reimbursed under Medicare Part B. Payment will vary by geographic location.

HCPCS1 Code	Description	2023 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.	$1,556

*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. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html. Accessed February 1, 2023.
2. Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) final rule (CMS-1738-F, CMS-1687-F, and CMS-5531-F). File DME23-A, January 2023 DME Fee schedule. Accessed January 2023.

Urgent PC Percutaneous Posterier Tibial Nerve Stimulation (PTNS)

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
64566	Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming	$ 118.35

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

Urethral Bulking

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
51715	Endoscopic injection of implant material into the submucosal tissues of the urethra and / or bladder neck ( billed 3 Units, this is per unit amount)	$ 370.93
L8606³	Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies	$ 246
L8606³	Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies (2 Units) $246 per unit	$ 492

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

Cystoscopy

2023 Uro CPT Codes and Medicare National Average Allowable Payment

CPT™ Code¹	Description	2023²
52000	Cystourethoscopy (separate procedure)	$ 241.66
52310	Stent Pull	$ 277.37
52204	Cysto/Biopsy	$ 381.18
52287	Cysto/Botox Injection	$ 389.77

1. 2023 Current Procedural Terminology (CPT®) Professional Edition. CPT is a copyright by the American Medical Association. All rights reserved.
2. CMS 2023 Physician Fee Schedule. Addendum B. Effective through December 31, 2023.

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

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

5.https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm

Reimbursement

Urodynamics

Optilume® Urethral Drug Coated Balloon

Eclipse™ System for Bowel Control

Urgent PC Percutaneous Posterier Tibial Nerve Stimulation (PTNS)

Urethral Bulking

Cystoscopy

Possible ICD-10 Diagnosis codes

Possible GI ICD-10 Diagnosis codes

Patient Resource Center