Reimbursement Summary

The following document has been compiled to use as a resource for reimbursement. Contained in the Reimbursement Summary are key BPH treatment codes and frequently asked reimbursement questions.

3171-018B 2018 Billing Guide

Reimbursement FAQ’s

What CPT code is used to bill medicare for the Rezūm system proceure?

Providers should continue to bill as instructed by the Medicare Contractor. We recommend the CPT 53899 for billing Medicare Contractors. Some of the Medicare Contractors have issued coding Articles that detail coding instruction. Some require that “Rezūm” is listed in Box 19 on the CMS-1500 billing form to avoid a delay in payment.

What CPT code is used to bill private payers for the Rezūm system proceure?

We recommend that coding for private payers is confirmed prior to billing. Some private payers with written policy continue to require CPT 53852 for billing Rezūm. The Rezūm Reimbursement Hotline staff will contact the private payer at your request and report back the code required by the private payer. The NxThera Reimbursement group will confirm and communicate any coding change with commercial payers that currently have written policy.

Does Medicare reimburse for CPT code 53899?

Reimbursement from Medicare varies by Medicare Contractor. As of December 2017, Palmetto Medicare does not reimburse for Rezūm as indicated in their written policy. No other Medicare Contractors have communicated non-coverage as of December 2017.

Is prior authorization required the Rezūm system proceure?

Medicare does not provide prior authorization confirmation. However, some of the private payers will review and communicate coding, coverage and reimbursement through a prior authorization process. The Rezūm Reimbursement Hotline staff will confirm coding with the private payer, and also provide the prior authorization requirements that the provider must complete to confirm coverage and reimbursement from the private payer.

How should conscious sedation be reported if used in the physician office?

If conscious sedation is used in the physician office setting, an independent, trained observer must be present to monitor the patient’s status. When provided by the surgeon sedation may be reported using CPT codes 99152-99153. The intraservice time begins with the administration of the agent and concludes at the end of personal contact with the patient by the physician providing the sedation. Billing of these services requires continuous face-to-face attendance. Coverage and reimbursement for conscious sedation varies by the patient’s benefit plan and should be confirmed prior to the service.

Are other procedures included in the payment for CPT 53899?

Related services are typically considered bundled and included in the payment for the unlisted procedure if billing 53899. Through December 2017, there were two Medicare Contractors that required billing CPT 53899 for the Rezūm procedure. The payment rate was equivalent to payment for CPT 53852 – the historical code billed for Rezūm based on the earlier recommendations from the American Urological Association (AUA). Code 53852 has a 90-day global period assigned to the procedure, therefore, the Medicare Contractors have also followed the 90-day global period when CPT 53899 is billed and Rezūm is identified in Box 19 on the claim form.

Reimbursement Hotline

Please contact our Reimbursement Hotline at (877) 731-9090 or via email at support@rezumreimbursement.com from 8-5 CST if you have questions that have not been answered by the resources provided above.

Additional information can be found at http://devicecoding.com/rezum/

Disclaimer: This has been prepared for providers of the Rezūm® procedure and is intended for informational purposes only. It does not represent a statement, promise or guarantee by NxThera concerning coding, coverage, or reimbursement. Coding, coverage and reimbursement can vary by payer and is subject to change. Check with the payer to confirm coding, coverage and reimbursement details.

References
¹Current Procedural Terminology 2018, American Medical Association, Chicago, IL 2017.
²OPPS and ASC Final Rule. Federal Register, December 14, 2017 (42 CFR Parts 414, 416, and 419); Corrected
³ICD-10-CM 2018. American Medical Association, Chicago, IL 2017.