On August 27, 2015, the FDA cleared for marketing the Rezum® System to relieve lower urinary tract symptoms secondary to benign prostatic hyperplasia. This procedure involves the transurethral injection of steam into the prostate. Once injected, the steam condenses to water, imparting convective energy to the tissue, causing cell death and damage. The technology uses radiofrequency (RF) to boil the water to create the steam that is injected, but does not impart radiofrequency directly to the prostate tissue.
Claims for procedures involving Rezum® should be reported using Current Procedural Terminology® (CPT®) code 53854. The claim should also indicate that the Rezum® procedure was performed in Box 19 on the CMS 1500 form (or its electronic equivalent).
Claims for procedures involving Rezum® transurethral steam injection should not be coded as CPT® 53852 (Transurethral destruction of prostate tissue; by radiofrequency thermotherapy). CPT® code 53852 is intended for transurethral prostatic tissue destruction technology that imparts radiofrequency directly to the prostate tissue.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.