Reimbursement

Medicare

Medicare coverage for the Cooled ThermoTherapy™ procedure with Prostatron^® and Targis^® systems, when performed in either a hospital outpatient setting or physician's office setting, exists in all 50 states.

Select a state from the dropdown below to view the 2008 Medicare rates.

Reimbursement Guide

Most commercial payors have established a coverage policy for Cooled ThermoTherapy™ treatments. Reimbursement amounts for the technical and professional component, when performed in either a hospital or physician's office setting, will vary by insurance product type contract.

Download the 2008 Cooled ThermoTherapy Reimbursement Guide

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

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

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 Cooled ThermoTherapy™.

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 Cooled ThermoTherapy 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 Cooled ThermoTherapy procedure with Prostatron^® and Targis^® systems.)

Learn more about Reimbursement by contacting Urologix with the Request Information form.