This Billing and Coding Article provides billing and coding guidance for the Rezum® procedure for treatment of benign prostatic hyperplasia (BPH).
On August 27, 2015, the FDA cleared for marketing the Rezum® System to relieve lower urinary tract symptoms secondary to BPH. This procedure involves the transurethral injection of steam into the obstructive prostate tissue. Once injected, the steam condenses to water, imparting convective energy to the prostate 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.
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.
CPT code 53854 for Hospital Outpatient (Part A) and Ambulatory Surgical Center (Part B) Facility claims.
Effective 1/1/2019, hospital outpatient departments (HOPDs) should use CPT code 53854 to report the use of the Rezum® procedure for the treatment of BPH.
For additional information, please refer to CMS federal regulations for Hospital Outpatient Regulations and Notices, final rule with comment period for the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for the Calendar Year (CY) 2022 (CMS-1753-FC) located at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientpps/cms-1753-fc
CPT code 53854 for Professional claims (Part B) Medicare Fee-For-Service (FFS)
CPT code 53852 (Transurethral destruction of prostate tissue; by radiofrequency thermotherapy), does not appropriately describe the Rezum® procedure. Effective 1/1/2019, claims for procedures involving Rezum® should be coded as CPT code 53854.
Documentation Requirements
- 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.
