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. Below is the national reimbursement amount based on 2021 rates, for specific amounts, please adjust the locality to your area by visiting the CMS website.
53850 Transurethral destruction of prostate tissue; by microwave thermotherapy (TUMT)
53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy (TUNA)
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
U.S. Centers for Medicare & Medicaid Services. (2021, January 20). License for Use of Current Procedural Terminology, Fourth Edition (“CPT®”). CMS. https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=1&CT=0&H1=53850&H2=53852&M=1.