October 16, 2026

In this episode, Scott, Mark, and Dr. Ray Painter share what they heard at the October meeting of the Urology Pharma and Tech Pioneer (UPTP) group—a monthly forum where urology practices from around the country compare notes on new technology, payer behavior, and office workflows. They discuss XIAFLEX acquisition costs now running above ASP plus six and how practices are moving away from buy-and-bill toward specialty pharmacy or other acquisition options, with a reminder that some states, such as New Jersey, restrict in-office dispensing. They review payer-specific payment problems with INLEXZO and ZUSDURI, early Medicare claim sampling, UPIC and RAC record requests, and Anthem prior authorization questions around prostatic artery embolization, and denials for PCR, quantitative urinalysis, and routine dipstick UA. The conversation also covers Altaviva, eCoin, biosimilars, appeal turnaround times of 90 to 120 days, and payers' growing use of AI in claims processing. The key takeaway: documentation and communication—inside the practice and across the urology community—are the foundation for getting paid in an environment that is changing MAC by MAC and payer by payer.

Join the Urology Pharma and Tech Pioneer Group
Empowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.
https://www.prsnetwork.com/joinuptp

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The Thriving Urology Practice Facebook group.
The Thriving Urology Practice Facebook Group link to join:
https://www.facebook.com/groups/ThrivingPractice/

October 9, 2026

In this episode, Scott, Mark, and Dr. Ray Painter tackle two areas where the details payers are watching can make or break payment. First, they look at why billing for injected and instilled drugs has become more complex: biosimilars that carry their own Q codes and NDCs, compounded drugs such as interferon being used during the BCG shortage, and rising acquisition costs that Medicare's ASP-based payment has not caught up with. Mark explains why the code and NDC on the claim must match the exact drug given, why most MAC policies call for an unlisted code for compounded drugs with pharmacy labeling and invoices as backup, and why practices should confirm coverage and pricing before the drug is administered. The team then turns to double denials—what to do when a correctly coded claim is denied again after the documentation has been reviewed. Using same-day stone cases as examples, they discuss adding a cover letter that explains medical necessity and context at the second-level appeal, when peer review or an ALJ appeal may be worth pursuing, and how to allocate limited resources as denials and audits continue to escalate. The key takeaway: build the internal team and processes to get the drug details right up front, and stay persistent on appeals when the documentation supports the work that was performed.

PRS Coding and Reimbursement Hub
Access the Hub

PRS Urology Coding and Reimbursement Seminar
Information and Registration

Join the Urology Pharma and Tech Pioneer Group
Empowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.
https://www.prsnetwork.com/joinuptp

Click Here to Start Your Free Trial of AUACodingToday.com

The Thriving Urology Practice Facebook group.
The Thriving Urology Practice Facebook Group link to join:
https://www.facebook.com/groups/ThrivingPractice/

September 25, 2026

In this episode, Scott, Mark, and Dr. Ray Painter break down the 2026 prostate biopsy coding changes and the documentation details that determine which code should be used. They review transrectal versus transperineal approaches, ultrasound-guided versus MRI-fusion biopsies, systematic versus targeted sampling, and when the add-on code for additional targeted lesions may apply. The team also discusses diagnosis coding, current denial trends, the risks of separately billing imaging guidance that is already built into the biopsy codes, and considerations for performing transperineal biopsies in the office. The key takeaway: prostate biopsy coding now depends heavily on approach, imaging method, targeting, and precise documentation—so getting the details right is essential for compliant reimbursement.

PRS Coding and Reimbursement Hub

Access the Hub

PRS Urology Coding and Reimbursement Seminar

Information and Registration

Join the Urology Pharma and Tech Pioneer Group

Empowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.

https://www.prsnetwork.com/joinuptp

Click Here to Start Your Free Trial of AUACodingToday.com

The Thriving Urology Practice Facebook group.

The Thriving Urology Practice Facebook Group link to join:

https://www.facebook.com/groups/ThrivingPractice/