Cooled ThermoTherapy Medicare Coverage - BPH Solutions - Non-Surgical BPH Procedure

Medicare Coverage

Medicare coverage for Cooled ThermoTherapy™ (CPT code 53850) and Prostiva® RF Therapy (CPT code 53852) exists in all 50 states, when performed in either a physician's office setting or hospital outpatient setting.

Always 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).

For additional Reimbursement information please call our Reimbursement Hotline at 888-454-8314.

Codes

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

Physician and Hospital Billing

CPT Code:
53850 Transurethral destruction of the prostate by microwave thermotherapy
53852 Transurethral destruction of prostate tissue; by radio frequency thermotherapy

ICD-9-CM:
600.01 Hypertrophy (benign) of prostate with urinary obstruction
600.21 Benign localized hyperplasia of prostate with urinary obstruction

(To ensure proper reimbursement, please refer to your Medicare carrier or insurance payor to determine the appropriate codes for submission. The above information is example only.)

Methodologies

Hospital
Outpatient Prospective Payment System
APC = 675 for Cooled ThermoTherapy
APC = 0429 for Prostiva RF Therapy

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 may 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 this non-surgical BPH procedure 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.)