On this episode, is Medicare really getting wiser and catheterss that suck? Welcome to episode 255 of the Urology Coding and Reimbursement Podcast. I'm your host Scott Painter with my co-host Mark Painter and Dr. Ray Painter. And on today's episode, we want to welcome back special guest Dr. John Lynn, a solo practitioner in Gilbert, Arizona, and the founder of the Thriving Urology Practice Facebook group. And John, you want to tell everybody, all our audience, about the Thriving Urology Practice Facebook group, those that don't know about it, and then how do they join? Well, I can't wait to provide more value to our audience. The Thriving Urology Practice Facebook group is a free Facebook group where like-minded USbased urology practices get together to share information because I hate keeping information behind a payw wall. It is free. Did I say that already? So, if it's free, I'll take three. Or if it's free, it's for me. And vendors, I know some vendors will listen to this podcast and think, well, I want to join. Well, sorry. Only urology practice people in the US, urology practices, MAS, office managers, physicians, a pretty much it. We I wanted to create a a a safe space for everyone to freely discuss what they like, what they don't like, tips and tricks, and how they can grow their practices and continue to survive and thrive in today's hostile environment. Well, John, we uh we really appreciate you joining with us and joining us today on this episode. And let's dive right in. Let's start talking about the wiser program which stands for the wasteful and inappropriate service reduction. So it's a new program coming in 2026 from Medicare. So let's dive right in. Do you uh John want to share a little bit more about what you know about this and Yeah. So something this came on my radar several weeks ago. I made a post about it in the in a Facebook group and it's a little bit concerning. I I'll just give you the the bottom line up front which is what believe it or not some something that the military adopted wiser is a new CMS innovation center project that creates hurdles. This is my my perception that creates hurdles for urology practices which will then delay care by implementing prior authorizations. Yes, prior authorizations for traditional Medicare for this. These are the three things that affect urology for number one incontinence control devices, number two sacral neurom modulation and number three impetence devices among among others in in certain states of the union. So what are some of the details? What is it? first of all is a demonstration project by CMS innovation center and as you said Scott it starts on January 1st 2026 in about three and a half months and also lasts for six years ending on December 31st of 2031 and who does it impact providers AP so physicians APS and also suppliers now why did they do that well the purpose is to save CMS and taxpayers money by reducing inappropriate use and possibly fraud, waste, and abuse. What does it involve? Well, initially for this goround for next year, it'll involve six different states. And if you're in one of these six states, you and I are hosed. New Jersey, Oklahoma, Ohio, Texas, Arizona, and Washington. So, if you're in one of these six states, starting January 1st, 2026, you are going to need to pay attention to this. But those of you who are not in those states, stay tuned because it may roll out much sooner than you would like. And as I already mentioned, only three of those service lines involve urology. the in incontinence control device, sacral neurom modulation and treat evaluation and treatment of uh male impetence. So let's look at let's just consider the impact and and I put some numbers figured out some numbers and determined that just within these states for the Medicare beneficiaries that's about 68.8 8 million people that is totally in in the Medicare beneficiary pool and that's about 18.5% of the total eligible beneficiaries that will be included in the wiser program. So that is a lot a lot of Medicare eligible people. Now, yes, not all of these Medicare elig eligible people are in traditional Medicare because this program does not impact those in the Medicare replacement plans. Al falsely known as a Medicare advantage plan. I call it Medicare disadvantage. So currently about 51% of eligible beneficiaries are in the Medicare Advantage program. So let's just say among about half of the people in the eligible states are going to be involved in the wiser program and and how does it happen? So right now if you are thinking about starting January 1st 2026 if you're thinking about providing sacral neurom modulation incontinence control device male impetence if you're thinking about doing that service there a couple of ways to go about doing it. One, you can get a prior oath from get this very important phrase model participants. When you start reading about this stuff, model participants, you have to get prior author from model participants before providing the service to avoid denial of payment or number two, which I think a lot of a lot of practices are going to be unfortunately defaulted into taking this route. The second route you do it is that you take your chances and provide the service upfront and then try to get the prior oath or post O in this case hoping that you get affirmed another euphemism the euphemism that they use in the program. Hopefully you get affirmed in your claim and get paid. So one you get the prior off beforehand. Number two, you try to get the authorization afterwards and hope and pray that you met the criteria to get paid. So what are the model participants? Model participants are these qualifying companies that perform prior odds. So think Medicare Advantage prior authorization programs because Medicare CMS is looking for partners such as those already in place by Medicare Advantage programs to perform prior os using artificial intelligence, machine learning and lastly humans to once again affirm or I like to call it authorize or nonaffirm as they call which is which simply is another euphemism to deny payment for services. And this is what's so perverse and misaligned about this entire program is. So how are these model participants paid? They're paid by the number of appropriate denials that they provide. Yes, they are paid by the number of appropriate denials that they provide and it's multiplied by the average reimbursement for the region for the denied claim for the year minus some performance measures such as initially overturned denials that are then approved on appeal plus patient satisfaction. So basically the bottom line is the more they deny the more money these model participants collect. And we can go into go-karting if you want to. Anyway, that's the long and short of it. Mark, what are your thoughts? Well, I mean, you summed it up pretty well. I mean, it the incentive is deny. So, it's going to be interesting to see how they set it up. They're really trying to lean into AI. So you can I mean that's the other part of this that these companies are going to be fairly light on humans and human support. So this whole process of prior authorization is going to be done by machines. So they're going to have to come up with those and yet and we don't know yet who's winning these contracts. Nope. There is. So, we don't know who's going to have each state. Um, they're going to be awarded in two three-year deals, right? So, these guys are going to be in place for three years when they get the awards and then they've got to renew based on how they perform or on the other side of the coin, how do they get, you know, did they make enough money? Because that's the other part of this. These guys are leaning into this at a gamble um as to what they can and can't get as far as money is concerned. And you know the target list that Medicare came up with is really targeted towards areas where the racks have been busy over the years and and you can you can kind of see how they connected those dots. So there is that piece that's out there and so and the the other and the alternative, right? So you're it is quote unquote voluntary, right? You don't have to participate in the prior off but the volunt it's more like volunttoled because on the back end you're going to if you if you don't get the prior off right the me the MAC actually is going to request your records before you get paid. Uh, now we're all used to this with your with the with the Medicare Advantage plans, right? That they all have this. And so this is Medicare copying the move of the private payers by adding prior authorization. And if they have success, meaning they've denied lots of coverage to patients who didn't fit the criteria, then they're going to roll this out probably to more. So that's the other side of this that's going to be of interest. Um, now the the flip side of this, obviously this is something the MACs are now going to eat a significant amount of chart review going forward for those who aren't participating with this prior off piece. And I'm assuming they're going to try and roll out or name the people that are going to be or the programs in the October, November time frame. So, you know, you lucky people in Washington and Arizona and Ohio and Oklahoma and uh are going to have a shot um at at least preparing for this. And of course, the big one, Texas. Um so, this is going to be an interesting experiment across the board. Uh, and the other one and and I asked John a little bit before we we started like I how are they going to set up a prior off based on the NCD for impotence? It is a very thin directive from Medicare that doesn't really have any really solid guidelines. Now, sacral neurom modulation, you know, that one was we we kind of all know what's there, the failed two drugs, blah blah. So, that one is generally something we can look at and see how they would put the AI in place to really drive a prior off for that particular service. and and in some ways, you know, that might protect a few of you up front from takebacks down the road. Um cuz we've seen that happen that hopefully everybody's got all of their boxes checked and everything and that they're ready to go. And I think workflowwise what we're going to end up seeing because we're patterning the patterning all of this to AI is how do you build a workflow checklist for each one of these areas that they're going to roll this in? And yes, do you participate? I would um I would think because that de that payment delay on the back end with a chart review a medical record request does slow down your cash flow um for those particular devices. So it is going to be a workflow issue. I think there's a way around it and it's not like we're unfamiliar with prior authorization. So unfortunately that is becoming now sanctioned by Medicare. So it's it's probably going to be everywhere pretty soon. And I think it's going to expand. Yeah, this is a big departure from traditional Medicare. In the past, they haven't really done a lot of prior odds, but now this is a big step. Six different states, 19% of eligible beneficiaries in just in in those states. And and for those of you who are listening, RACK means recovery audit contractors. These are bounty hunters looking for mistakes that you made. and they make money by catching you making those mistakes. And MAC are Medicare administrative contractors. I believe there are 16 in the US that administer payment to your practices. We like to throw a lot of acronyms and shortcuts, but I want to make sure the audience understands because everybody's knowledge level is different. Yeah. Yeah. Appreciate that. I'm definitely but you definitely get how now participate in conversations in different areas where sometimes you walk away thinking I didn't understand a thing that those guys said because they use too many acronyms. So thank you for that. I I forget that even though I've I've experienced it on the other side. Um so Mark you had mentioned I just got a question for both you and and John. uh you'd mentioned that a lot of these targets were subject of the were subjects of the racks in the past. Do you think the common theme for all these are their very high ticket they're very high they're very costly um devices and procedures that they're targeting. Is that the is that the lowhanging fruit that they're looking at? I think there's a couple of things that are behind this. Um, one is yes, they are high ticket items. Two, they've got the data because the racks did recover a lot of money going after claims and reviewing them after they'd already been adjudicated by the max. So essentially if if you step back into their shoes and you say look we gave physicians trust and they abused it and we gave the max trust and they didn't watch Medicare's money the way that they were supposed to. We found that out by paying these folks to go and look at things and they recovered a lot of money. So this is an obvious next step. Let's put this up front. we've you see it in the private sector. So, it's kind of one of those easy political cells in all of this. So, I that's where I think it all really kind of boiled down into they they're reasonable volume. So, they're not ultra high, but they're reasonable volume services. And the spread, the geographic spread is one that gives different types of geography. It spreads it throughout the country to some degree, puts it on under different MACs. So it's, you know, or the administrative contractors. So from that standpoint, you can kind of see the logic. And then the the other piece that's also big is that most of these areas have NCDs or national coverage decisions that have been published. Now, not all of them. Some of them they're using uh local coverage decisions or local coverage articles and coding to actually focus on those areas. And those aren't necessarily ones that we have in urology. The urology based ones are all NCDs, but they expanded into like knees and and electrical stimulation and skin substitutes places where they have other guidance published out there so that essentially you're not turning loose these new project in innovations without a previously established Medicare payment policy or coverage decision that everybody has access to. So, there's there's some weird logic in this um from their side as they go through all of this, but it is money. That's the other part of it is it's they've got that backing that they've recovered money for for services that were provided that didn't meet the criteria. Ray, anything to add? Let's see. was a yoga bearer that said this is deja vu all over again. So true. Well, I was uh you've heard me tell you before I was on a national advisory committee committee for United Healthc Care during the time that they instituted prior authorization. Now, I was in a unique position because at the same time, the state of Colorado had a courtordered uh advisory committee for United Healthcare uh to look at things. So, we were I was looking at things from the payer side of view on the national level and from the provider side on the local level. And and from what we saw, Mark, those companies are going to make a lot of money because if it fit the same model of United Healthcare, those prior authorizations were more like a speed bump that some docs were not willing to take the time to go over. United Healthc Care saved hundreds and hundreds of millions of dollars in the first year or two they instituted that program. But in Colorado, we proved that if a doc really needed that test and and answered the right questions, they could get authorization at any time. So, in this case, it's going to depend on the physicians as to how that really works. This doesn't compare to an X-ray that you could get or do without probably, but if a doc really wants to get this procedure done for their patient, they should be able to get it done. So, you're going to have to be diligent and do the documentation and play the game by the rules or else those companies are going to make a lot of money. Yeah, Ray, the problem is the rules are are nebulous, especially as Mark said, the NCD, the national coverage determination for impetence is vague unlike sacral neurom modulation, right? So how I guess it's a cat and mouse the replace the the program model participants we'll call model participants of course it doesn't it doesn't they're not referring to us the docs they're referring to the authorization entities the model participants have to come up with a set of rules and we I guess we need to find out from them fall this year once the model participants entities have been selected. We need to figure out what they are. So I I'll definitely as soon as I find out I'll share it in the thriving biology practice Facebook group. We need to figure out what the rules are so that we can on our end perform the necessary work and also the unfortunately the documentation the bane of our existence the documentation so that we can provide the necessary care for our patients. And anytime humans are super super simple I figured this out. We we want to we want to thrive and survive in the easiest way possible. Whenever you put up hurdles, humans are lazy. We're lazy. Anytime you put up a hurdle, we're less likely to perform that behavior. And as you said, United Healthcare Insurance Companies, they know this. Medicare knows this, too. So I think this is just another way to deter performance of some of these services because it's another hurdle that we have to deal with death by a thousand cuts. Thanks John for bringing that up because you I I left out one key point that I wanted to make and that is a lot of that work as we proved in Colorado is on the back end. you know, you have to keep pushing for what you need to do for your patient and and eventually you'll get there. It's uh they don't deny good care for patients. They do deny request for care. So, whatever the rules are that are un unreal, we need to fight it. And it's going to be up to you guys in those states to fight it first. You're setting the tone. So Mark, John, Scott, educate all these folks as to what they have to do. It's going to be important. Well, the big big winners out there are going to be these model the the the model participants. What are they called again? The model participants. The model participants. And the losers looks like it's going to be a lot of providers, a lot of physician and a time and the patients may have delayed care, may not get the care they they need if the if the urologists and a out there aren't aren't able to get that approved. That's that's got to be a better way, but this is what we have to deal with now. Yeah. Well, go ahead. Yeah. I yeah I I was going to say one of the things is about the model participants in this right if none of the physicians participated because it's voluntary right they were willing to put their records into the MAC so if everybody said forget it the model participants wouldn't make any money and the max would be buried in paperwork work. It would slow down your payments, but you know, is that a viable bite back in this whole thing? Or does the next move then become Medicare essentially saying, "Okay, we tried voluntary, you guys didn't play, now it's going to be mandatory without any testing." So, that's that's one thing I think that's out there. And the other one, of course, is that as they go through this, as with any game, if you know the rules, you can you can play the game. And if you answer all the questions correctly on the prior off, you get the prior authorization, you submit and get paid, as Medicare is going to say. Do they still know that, you know, there are people out there? And one of the problems, of course, that they're trying to guard against are the bad actors. Okay, I answered the questions correctly. I got the parath. I got it paid for, but then are they going to go back and do documentation review to make sure that the docs actually did what they said they were going to do, which means they're still on the rack target list on the back end. So it's, you know, it I'm not totally convinced that these Prior O guys are going to win big. Yeah. It's going to be a gamble. Yeah. So we're going to we're going to figure out how to appropriately document after providing these service the necessary workup and stuff. The bad actors are also going to do the same thing. They're going to figure out how to do the documentation, beat the AI and the machine learning so that they get they get the prior oath and like you said, will the recovery audit contractors then come back even though you've gotten the prior O with the intent to to decrease profit waste and abuse even though you've met the criteria for the prior o provided the service. Now, will you be punished again by the recovery audit contractors coming back to audit your charts? Right. Jeez. Yeah, that's crazy. That's a great point. Crazy. It's And it'll be interesting to see which companies step up to become these project participants. And so that's going to be another piece that's out there. I mean, in some ways, do you want it to be the racks, right? or as a rack auditor, if I'm thinking this is eventually going to replace me, I'm going to go into this side of the business as well. And then I can do both. I can do the front and the back and I could start making money on both ends of the equation. That's the long game for them. Well, this should start with the specialty society uh the specialist determining the appropriate care and then once that is established, you know, we should be united in fighting for the rules to fit what's best for the patient. And we're already behind, right? because well but so what I'll say is SUFFU totally redid the guidel neurom modulation and it has not been added to the national coverage decision. So already, and this has been out for a couple of years, already we're out of alignment where Medicare has rules in place that are not matching the specialty society's recommendations of how to treat a disease state. So we're already mismatched. That that sounds like a a Congress thing of saying that uh Medicare should align with specialty recommendation. Yes, I agree. And this is now you got me wound up on the bully pulpit side, but you know, we're we're seeing in the proposed rule that the current approach that the CMS has taken is really more or less to remove the physician decisionmaking process in work RVUs, practice expense RVUs, and Now in this side, you know, again, stepping in to ignore what physicians are recommending for patient care. So, you know, this is a drift that we've seen for a number of years that is going on, but it's kind of culminating or coming into place right now that we're seeing some significant moves by Medicare to start grabbing the control of the Medicare ship. I mean, they've had a significant role in it before, but you know, LCA's were one piece, right? Before you had LCDs that required physician input and they had 90-day reviews. Now LCA's a a Mac can actually just publish a coverage guideline telling you how to code for things without the same commentary without the CS. Remember the CS? So, it's there's there's a lot of this that's been drifting that way. And this just seems like yet another step in trying to drive health care, you know, as the payers do from the commercial side from a financial side of the equation. And, you know, more and more I've heard this more frequently, who runs healthcare? Wall Street. Yeah. Unfortunately, that that is getting scarier and scarier because they've always had a jaundist eye look at physicians involved in the payment issue. Mark, you know that from the time we dealt with relative values back in the 80s. Yeah. And late 70s, uh they were trying to take physicians out of the equation on the payment side. But it's really scary if they're trying to take physicians out of the equation on the clinical side of medicine. And that is a fight I think eventually physicians should be able to win if we fight it in the right way. So for for those of you listening who are kind of lost in the in the translation there, I I'll try to simplify it. What Mark is saying is that in the proposed 2026 physician fee schedule, Medicare CMS has kind of disregarded the stuff that we've been providing. You know, some of the emails that you've been getting, hey, tell us how long it takes, how much effort it takes for you to perform a certain procedure. Those are ruck surveys, relative value unit uh committee surveys. CMS has decided to kind of disregard the information that you provide regarding how much work it actually takes to perform it particular procedure and then try to take that into account when they value your services. Don't get me started about being gaslighted into thinking that your value is dictated by somebody else. But I I digress. So your value is now not being dictated by what you suggest, but instead some arbitr seemingly arbitrary valuation by an entity. So that's what's going on with the 2026 proposed physician fee schedule. And LCA is local coverage article and LCD is local coverage determination to decipher some of the acronyms. More lingo. Thank you again. All right, we we probably should move on to our next uh discussion. Any final thoughts on the wiser discussion before we move on? Yeah. Uh number one, look for the list of CPT codes that will be impacted for the urology services. Look for the model participant list and figure out how to engage them for the prior oaths in the fall of this year for the for the six states involved. And as Mark said, be aware of the LCDs, LCAS, NCDs for the actually the LCDs and NCDs for the involved services and definitely figure out what you need to provide the necessary documentation. Be mindful just like any other claim. Be watchful for inappropriately denied claims. That is what is going to be really important to you. You will need to scale up your billing maybe prior off team if you perform a lot of the incontinence device sacral neurom modulation in impotent services in 2026 to Medicare beneficiaries and as we already said documentation is key appeal the inappropriate denials and very importantly we need to advocate collectively as Mark Ray and Scott you've said numerous times in prior podcasts we have to participate in our society's the political action committees, contributing to the political action committees. If at the very least you should be part of your local state medical associations and the nuclear option is to not favorable not favorable suggestion, but to get out of Medicare, opt out of Medicare, go cashbased so you don't have to participate in this game. I just thinking out of the box for all of you. Mark Rainey, final thoughts on Wiser before we move on. So, the the thing I'm going to just lay out there is obviously, you know, you're going to be looking as we look at this and John's right, we'll narrow down the CPT codes. We'll, you know, as we get that and we'll we'll be announcing that as well and and really trying to keep everybody up to date. But as you're thinking about all of this, generally you're thinking about neurosacre modulation. So that's your SE 64561 and 81. Those codes are going to be part of this program you're thinking about from the incontinent side. Any bulking agents are going to be a part of that. That's part of the NCD. Uh so that's another big one. And then of course any any impetence treatments with that vague one that's out there. That one's going to be another one that we're going to have to navigate. So those are kind of the broad categories um that are out there and and artificial sphincters obviously are in that as well. So that's kind of the areas that you're going to be leaning into this. You should take a look at the NCDs and that are out there, the national coverage decisions. And just so you know them, the neurosacral modulation NCD is NCD230.18. The incontinence controls is NCD230.10 10 and the impetence is NCD230.4. So you can put that into Google or your nearest surfing mechanism and bring up those national coverage decisions and you can see what we're talking about. It's going to be interesting to see how they translate that into a prior AI. And we'll also put those in the uh episode page. If you're someplace where you can't write those down and don't remember those, if you go to prsnetwork.com255 for episode 255. Ray, anything to add? Well, we we talk about getting paid a lot, but we want to keep in mind that our main goal is good patient care and taking care of those that need us. So don't don't lose sight of that as you're going through this fight for what's right. Very important. Okay, let's move on to uh the second thing we wanted to talk about. Uh John wanted to ask Mark a question. Let's see. Uh let's talk a little bit about catheterss that suck. This is a this is a repeated question asked by a lot of folks in the thriving urology practice Facebook group regarding the the steerable uro catheter tackling large stones documentation requirements and for which device can you use the facility for for the facilities to use C9761 uh which is systo ureiththoscopy with uridoscopy and or pyoscopy with lithotropsy and urethral caization of steerable vacuum aspiration of the kidney collecting system urer bladder and urethra if applicable and in parenthesis the definition says must use a steerable urethral catheter close and yeso device is very easy to say oh yeah we use the calixo so C9761 facilities can use that code to get reimbursed but What about the newer technologies, the newer steerable catheterss that are out there such as the clear Petra Dier has one as well? Vethan has one as well. What about those devices when when you use it? And also some of the docs are struggling with the documentation requirements. What say you Mark? Number one, let's go to documentation requirements. uh you are going to need to mention in your note that you used a steerable device, a steerable suction assisted device. Um so that is one thing that is going to need to be added into your operative note. Um you're also going to want to make sure obviously with everything that the medical necessity was there, why did you choose to do that? That should be in most of your notes. And when I see that that's, you know, clearly you've got a heavy stone burden, you got big stones. There are a number of different reasons why that makes sense, but do add that additional information that that technology was utilized. So that's that's one thing. I I think it's debatable overall whether or not that is something that really should be required, but I really recommend that you do that. Um, so that's that's one thing that's out there. So then with regard to the different types of of options that we have right now, I do know that there are lots of folks that are using the C9761 with some of the sheets and some of the steerable catheters that are not Kixo, which it was the group that originally we'll say submitted the application for the pass through tech the TPT the trans transitional pass through technology code. So that definition and Medicare and CPT always design their codes not to be specific to any one technology but to a type of technology. So one of the things that you've got to consider is interpretation of that particular code. So people are using it, people are getting paid. There is an argument that you know a catheter is a catheter and steerable is steerable and ultimately that was the intent of that code. But the code does have that special parenthetical notation that it it must be a steerable catheter. So the question becomes as we move down the road, what are the payers going to do? Now in a in that interpretation now most of what we're seeing there is a device offset so that the device should be reported to the payer. So they should know exactly what they're paying for when Medicare pays for that. And I think that's your biggest concern with this particular code is Medicare. Private payers are all over the board in the payment side. And that's going to be a basically a contract by contract based on your ASC's or with the hospital because this is not about the physician getting extra payment. This is about the facility payment overall. So I do think there is some some protections as you go through this. If you're providing the invoices, the payer knows what's going on. The device offsets are set. To me, that gives me a little bit more comfort in using that particular code for the sheath. As long as that is fully disclosed upfront and the offsets are paid from Medicare, you've got some precedent that yeah, this was fully disclosed. It went forward. This is the way we're going to do it. Are the racks going to come back somewhere down the road and determine that the max did it wrong? That's the question that I have and that's the one I don't have the answer to. Yeah. When Klexo developed the original CVAC device, it was a steerable urethral catheter, meaning on the proximal end, you can turn and steer that catheter. But the newer the new kids on the block, they don't have that steerability built into the catheter. Instead, they use a urethoscope to steer the the steerable ureo catheter into the appropriate kalouses to suck out the stones. So is it steerable? The the definition of a steerable uro catheter in my mind clearra and all the the some of the other ones they're being steered by a urtocope. So by definition they're steerable. That's that's one perspective that I have. Secondly, the second version of Kixo's CVAC device, where is the catheter? Where's the steerable ureal catheter? because they develop a uberoscope with a large suction board that's dedicated for sucking out stones and debris and and and clots whatever is that a steerable urido catheter and if you're going to say it is and they can use C9761 for for facilities to get paid then the argument goes well why can't the clearra and the va device and the thornier device, why can't they be deemed as a steerable ubutal catheter? So, that's the question I have. If that's the case, then nobody gets paid, right? It is it is going to be interesting to see if this gets challenged. I mean, it is relative to all that we do in healthcare, relatively small on the scale. Um but you know it is that area that I think the arguments are there that fit those definitions as you've laid it out that you know a duck is a duck right that the intention of this was to allow for suction assisted devices to to go forward and and get paid extra as a transitional pass through technology. and we are submitting most people are required to submit invoices or they are required to report what they're using. Now that's not necessarily true in some of your ambulatory surgical center situations, but it should be with the device offset as they roll through this. So I think there's again some protection there. I just want to add that note of caution that even though the argument is good, it's still an argument. And that's the and that's where we always fall on these things is the the vagueness of where it is the and you know, can it win in a court of law under an ALJ? Probably. But in the end, that argument of going all the way up to the ALJ while your money's sitting in somebody else's pocket is never a fun one. Um, so, you know, I I'd love to fullthroatedly endorse that that's the right way to go, but I but I do have to add that note of caution that, you know, that interpretation could be there. That argument may need to be made. And that's a big dollar amount that we're talking about. And again, it's on the facility side of things. Yeah. Only. And you know that that big dollar amount is is you know what rack the rack auditors do tend to focus on. So that's that's the question in my mind. The problem is without a clear path, clear definition to payment, facilities are reluctant to let urologists use this very powerful and effective device to clear large stones from a patient walle anesthetic, which means the patients ultimately suffer without a clear definition on this code. that is, as you said, Mark, it's not used a lot, but it's important for that patient with a stone burden. Yeah. Yeah. Totally agree. Like I said, I wish I'd I I felt more comfortable saying, party on, Gar, go for it. But no, I I you know, that's kind of I think I I need to put that note of caution in. But I do, you know, with the caveat that yeah, there a lot of that's being reported up front and endorsed by the max seeing full well what actually is being utilized with that particular code with the invoice offsets. So and for those who who are lost when Mark said ALJ, ALJ, administrative law judge is the level of of appeal when your claim is denied. is, I believe, the third level of appeal. Unfortunately, I've had to deal with ALJs in the past in in trying to fight for a claim that was over $8,000. Anyway, that's what that is. It's a third level of appeal when you appear in front of a judge to argue your case in a denied claim. And that applies to that one claim. That apply the ruling made by the ALJ applies to that one claim. So, you can't take that ruling and say, "Hey, here's another denied claim in the future." Nope. It doesn't work. You have to you have to argue that denied claim in the future completely separate from the denied claim that you won today. Yeah, it's crazy. All right. It is crazy. Okay, let's wrap this up here. Uh, we want to thank Modb for supporting this episode. If you're in the market for an HRO or practice management system, you can go to modad.com/prs network for specials for our listening audience. All right, let's get some final thoughts. We'll see. We're going to save the last word for John, so let's go. Final thoughts, Mark. We've got a lot moving with Medicare. Um, you know, we kind of got off onto a tangent a little bit as far as the the proposed rule and everything that's out there, but for those of you in the states where the wiser program is going to be implemented, it's another thing to add to the chess board that you need to navigate and decide how you're going to go go forward. So, you either play the game with the wiser folks when they get that in place or you're submitting your records before you get paid to the MAC. So, that's a choice that you can make. Um, and certainly one that as we see these things roll out, probably the easier pathway is to go through the wiser protocol that to speed your money up. So, we'll have to see where that comes in, where those really lay down and what you need to put in place. But you can get an idea again by looking at the the NCDs that are out there that we gave you. And you know, with regard to the clixo and the sheets and the C9761, you know, that is one of those things where it's a calculated risk. It is a lower risk, I think, because you're submitting your information in for the invoice, but just know that there is some risk and that may be the hesitancy of some of your your facilities to work with you there. So, do your part and make sure your documentation includes the fact that you use that scope with the suction assistant and it was steerable. Ray, final thoughts? Well, some things change frequently, but yet it never changes. You have to be sure your documentation is is complete and accurate for how you get paid and follow up on all the claims and that's not going to change. All right. And the final word to John. I I know the purpose of PRS is to make urbologists life lives easier so our practices thrive so we have time to enjoy our lives and to that end I'm going to quote something that someone mentioned Dr. Cheryl Sheay mentioned in the Thriving Eology practice Facebook group and that is don't trade time you may not have for money you do not need. Understand why you're working the way you do. Understanding your why and do things that bring you joy. For a lot of urologists you you want to do everything for everybody. And I've lo learned long ago, whether that is urology or life in general, you can't make everyone happy. You can't be all things to all people. Do things that you enjoy doing and go all in and just drop the things that don't bring you joy in life. That's going to help you have that light or lighter step as you come into your office, as you walk into the operating room. Do the things. pursue the things that the the service line, the procedures, the the patients that you enjoy seeing so you can at least continue to play in this game and continue to work instead of burning out. Back to you, Scott. Great advice and that applies to so many things. All right, we want to uh also let you know that the urology advanced coding and reimbursement seminar is going to be in December in Las Vegas and in January in New Orleans and it is super important this year to attend. You hear these discussions that we're having and a simple hour on a podcast doesn't cover it. You need to come down, join us at the seminar, really participate, add your two cents, hear what others are saying, and figure out the best way forward for your practice. It's getting more and more difficult to practice the way you want to practice. And as John mentioned, you've got to really think about how you want to practice and what you want to do with your practice. And one of the best ways to do that is joining us at the seminar so you can really understand the landscape of what's going on. We have these discussions in detail with a group of very uh like-minded people that can contribute and are in your same situation and give you those suggestions that you may not think about it. Practicing in the silo is no longer an option for urology uh for anybody. It's it's just not there. So, we encourage you to come down and join us. You can go to prsnetwork.com and right there on the homepage, click on the the seminar registration button and get registered. We'd we'd really love to have you there. All right, that's all we have for today. Thank you all very much for listening. Take us out, John. Happy coding everyone.