Medicare & Insurance Reimbursement

Reimbursement

Medicare coverage for Cooled ThermoTherapy™ and Prostiva® RF Therapy exists in all 50 states when performed at a physician’s office, hospital outpatient or ambulatory surgery center.

Refer to the AMA website for current information on Medicare Coverage rates for your area (https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do?submitbutton=accept)

Reimbursement Codes

The current codes and billing guidelines for both Medicare and commercial payors include:

CPT® Codes/Descriptions

53850 Transurethral destruction of prostate tissue; by microwave thermotherapy (TUMT)

53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy (TUNA)

Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.

Hospital APC Codes

Outpatient Prospective Payment System (OPPS)
APC = 5373 for Cooled ThermoTherapy
APC = 5375 for Prostiva RF Therapy

ICD-10-CM Diagnosis Codes

Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. This information is provided as an example only. It is essential to refer to the Medicare Local Coverage Determination (LCD) in your state for verification of appropriate diagnosis codes.

Enlarged prostate N40

  • N40 is not a billable ICD-10-CM diagnosis code and cannot be used to indicate a medical diagnosis as there are 4 codes below N40 that describe this diagnosis in greater detail.
  • Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.
  • This is the American ICD-10-CM version of N40. Other international ICD-10 versions may differ.

Includes

  • adenofibromatous hypertrophy of prostate
  • benign hypertrophy of the prostate
  • benign prostatic hyperplasia
  • benign prostatic hypertrophy
  • BPH
  • nodular prostate
  • polyp of prostate

Clinical Information

  • A benign (noncancerous) condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine.
  • Increase in constituent cells in the prostate, leading to enlargement of the organ (hypertrophy) and adverse impact on the lower urinary tract function. This can be caused by increased rate of cell proliferation, reduced rate of cell death, or both.

Enlarged prostate billable codes under ICD-10-CM

  • N40.0 is a billable ICD-10-CM diagnosis code N40.0 Enlarged prostate without lower urinary tract symptoms
  • N40.1 is a billable ICD-10-CM diagnosis code N40.1 Enlarged prostate with lower urinary tract symptoms
  • N40.2 is a billable ICD-10-CM diagnosis code N40.2 Nodular prostate without lower urinary tract symptoms
  • N40.3 is a billable ICD-10-CM diagnosis code N40.3 Nodular prostate with lower urinary tract symptoms

N40.1 Enlarged prostate with lower urinary tract symptoms

  • N40.1 is a billable ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
  • Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.
  • This is the American ICD-10-CM version of N40.1. Other international ICD-10 versions may differ.

Applicable To:

  • Enlarged prostate with LUTS

Description Synonyms

  • Benign prostatic hyperplasia w/ urinary symptoms
  • Benign prostatic hypertrophy (enlarged prostate)
  • Benign prostatic hypertrophy with outflow obstruction
  • BPH w incomplete bladder emptying
  • BPH w lower urinary tract symptoms
  • BPH w nocturia
  • BPH w straining on urination
  • BPH w urinary frequency
  • BPH w urinary hesitancy
  • BPH w urinary incontinence
  • BPH w urinary obstruction
  • BPH w urinary retention
  • BPH w urinary urgency
  • BPH w weak urinary stream
  • Incomplete emptying of bladder due to benign prostatic hypertrophy
  • Lower urinary tract symptoms due to benign prostatic hypertrophy
  • Nocturia due to benign prostatic hypertrophy
  • Straining on urination due to benign prostatic hypertrophy
  • Urinary frequency due to benign prostatic hypertrophy
  • Urinary hesitancy due to benign prostatic hypertrophy
  • Urinary incontinence due to benign prostatic hypertrophy
  • Urinary retention due to benign prostatic hypertrophy
  • Urinary urgency due to benign prostatic hypertrophy
  • Weak urinary stream due to benign prostatic hypertrophy

Use Additional code for associated symptoms, when specified:

ICD-10-CM Coding Rules

  • N40.1 is only applicable to adult patients aged 15 – 124 years inclusive.
  • N40.1 is only applicable to male patients.

ICD-10-CM N40.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):

  • 725 Benign prostatic hypertrophy with mcc
  • 726 Benign prostatic hypertrophy without mcc

Physician

Medicare Policy specifies that payment for physician services is based on the lesser of the actual charge or a payment amount computed under the fee schedule. The actual amount paid by Medicare to a participating physician is 80% of the fee schedule, or their actual charge, whichever is lower. Physicians will bill the Medicare beneficiary and/or secondary insurance company for the remaining 20%.

Private payors may have different coding and reimbursement guidelines, especially regarding new procedures. Coverage and reimbursement amounts will also vary based on contractual arrangements with the individual payors. Many payors follow Medicare policy in paying for the Cooled ThermoTherapy or Prostiva RF Therapy, effective non-surgical BPH treatments.

Regardless of the payor, a full and accurate medical record is an element in obtaining any coverage decision. Many payors may require that physicians request prior authorization before performing a given service. Although prior authorization for these non-surgical BPH procedures is recommended, and may be required in certain cases, it is not a guarantee of payment.

Please contact the patient’s third-party payor for their specific coverage guidelines regarding the procedures.