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August 2, 2018

Billing and Coding for the Rezum® System for Benign Prostatic Hyperplasia (BPH)

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.

Rezum received FDA 510(k) clearance on February 27, 2018. Available evidence has shown that the Rezum procedure for treatment of BPH is reasonable and necessary. The procedure is covered for FDA approved indications if the appropriate criteria are met.

For Medicare Billing: Hospital Outpatient Setting or Ambulatory Surgical Center:

  • Effective January 1, 2018, claims billed for procedures involving Rezum should be coded as HCPCS C9748.
    • Documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450 form) or the equivalent 5010 electronic claims

Physician’s Office:

  • Claims billed for procedures involving Rezum should be coded as CPT 53899.
    • Documentation must be included in Box 19 on the CMS 1500 form or the electronic equivalent to indicate that the Rezum procedure was performed.

NOTE: Claims for procedures involving Rezum steam injection should NOT be coded as CPT 53852 because the technology does not apply radiofrequency energy to the prostate. Prostatic tissue destruction is accomplished via steam generated by RF, not by the RF itself.


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