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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
OH
OHODI-MRF-CPT-52356-CMH
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Ohio Department of Insurance (ODI) & CGS J15 MRF Index — Columbus / Cleveland MSA
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Franklin County, OH
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Filing / IDR Window: 2026-12-02
[OHODI-MRF-CPT-52356-CMH] Anthem BCBS-OH & Medical Mutual Urology / Lithotripsy ASC MRF Rate Spread & O.R.C. § 3901.389 Prompt-Pay (CPT 52356 / 50590)
Commercial payer MRF negotiated rate benchmark, NCCI Procedure-to-Procedure (PTP) modifier defense, and Ohio Revised Code § 3901.389 18% statutory late-payment interest demand for Urology & Lithotripsy Surgery Centers (CPT 52356 Cystourethroscopy with Ureteroscopy, Laser Lithotripsy & Indwelling Stent Insertion, CPT 50590 Extracorporeal Shock Wave Lithotripsy ESWL, and CPT 55866 Robotic Radical Prostatectomy).
Cohort MRF 75th-Pct Value
$1,490,000
Target % of Medicare
11.0% MPFS
Statutory Authority
OH-GPCI-2026-CMH (Medicare Locality 15202-00 & O.R.C. § 3901.389 18% Prompt-Pay)
ERISA / Timely-Filing Window
370 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-52356 | Cystourethroscopy, with Ureteroscopy and/or Pyeloscopy; with Lithotripsy & Indwelling Stent | CLAIM | 460 | $1,480.00 | $3,290.00 | $4,120.00 |
| CPT-50590 | Lithotripsy, Extracorporeal Shock Wave (ESWL) (ASC Facility + Professional Fee) | CLAIM | 320 | $1,350.00 | $2,980.00 | $3,740.00 |
| CPT-52000-59 | Diagnostic Cystourethroscopy (Modifier 59 / XU Distinct Procedural Service Defense) | CLAIM | 890 | $195.00 | $410.00 | $515.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Buckeye Urology & Stone Surgery CenterOhio Valley Lithotripsy & EndourologyGreat Lakes Urologic Surgical AssociatesCentral Ohio Continence & Prostate InstituteCuyahoga Ambulatory Urology Partners