How to get reimbursed for BPH water vapor ablation

How do I code for convective water vapor ablation for lower urinary tract symptoms/BPH (Rezum System)?

Up front, we must disclose that Physician Reimbursement Services has contracted with NxThera to provide support for offices that have billed for Rezum. In this article, we will provide the basics as we know them at this point.

Until recently, you could find an article published by the AUA Coding and Reimbursement Committee recommending the use of CPT Code 53852 (Transurethral destruction of prostate tissue; by radiofrequency thermotherapy) online. That article was removed from the AUA website in August. A search of www.auanet.org for Rezum at the time this article was written did not return any information. However, there is an archival post on the AUA website referencing Rezum (bit.ly/Rezumclearance).  

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The recently published public transcript from the September meeting of the CPT Editorial Panel was released officially on Oct. 13, 2017 and can be found at bit.ly/CPTpanelsummary. Item 21 on this report indicates that the panel decided to “add a code 538X3 to report water vapor or steam thermotherapy for destruction of prostate tissue.” Once released for use Jan. 1, 2019, this will become the correct way to report Rezum.  

How to report Rezum prior to Jan. 1, 2019 will likely be a topic of discussion, with different answers depending upon the payer. In the end, coverage and payment of this procedure will depend upon review of the clinical evidence by payers that is presented by urologists and patients that feel the procedure is the best clinical pathway to treat a patient’s BPH.

Next: Two possible coding pathways

At this point, we see two possible coding pathways:

• Continue to report code 53852 (Transurethral destruction of prostate tissue; by radiofrequency thermotherapy).

• Report Rezum with unlisted code 53899 (Unlisted procedure, urinary system insert “Rezum Transurethral destruction of prostate tissue; by radiofrequency thermotherapy” or “Rezum water vapor or steam thermotherapy for destruction of prostate tissue”) in box 19 of the claim form to assure prompt payment.

You will need to consult your payer prior to providing this service to determine the correct approach for the payer and to make sure the service is covered. Consulting a payer should consist of reviewing current posted coverage policies and following instructions provided. If the coverage is unclear or there is no information posted, we recommend calling the payer for coverage and payment requirements.

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Other points to consider:

• Payers may continue to request the use of code 53852 for ease of adjudication, or a payer may develop an edit on the unlisted code that allows processing of the service with the unlisted code without review of each claim.

• Payers may also choose to require the unlisted code and require a review of each case submitted.

• Payers may choose to consider Rezum as a non-covered service, allowing the practice to bill the patient directly for the service under the practice’s current fee schedule rate.

• If the payer does not provide any instructions or information on current coverage and/or proper reporting of Rezum, it is left to the practice to choose to continue to report code 53852 unless the AUA or the American Medical Association publishes a coding recommendation indicating otherwise, or to use 53899 as noted above.

Note: For payers that do not provide information on coverage or payment, remember that you will need to follow contractual instructions if contracted with the payer, which may or may not allow for collection of payment from the patient prior to claim adjudication, and likely will require appeal or submission of supporting materials for proper claim adjudication. For those payers with whom you are not contracted, collection from the patient is allowed; however, practice processes used for other services should be followed.

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Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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