It is the provider’s responsibility to verify appropriate coding, and code to the highest level of specificity to report a patient’s condition and services rendered. The following may provide applicable coding information for the Prostatic Urethral Lift procedure using the UroLift® System. Some payers may have unique coding requirements; please verify coding with the health plan.
The UroLift System is FDA cleared for the treatment of symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral and median lobe hyperplasia, in men 45 years of age or older. Following is the most common ICD-10 BPH diagnosis code associated with the Prostatic Urethral Lift procedure using the UroLift System. It is the provider's responsibility to code based on the patient's condition(s) and history.
Physician Coding and Medicare Payment Information
*CY2020 Conversion Factor: $36.0896.
All rates are national, unadjusted Medicare allowed amounts; actual payment will vary by site of service, geographic adjustments and patient co-pay and deductible responsibility. Rates referenced in this guide do not reflect Sequestration adjustments which are automatic reductions in federal spending that will result in a 2% across-the-board reduction
Using add-on codes: CPT code 52441 is used to report the initial UroLift System implant and add-on CPT code 52442 reports each additional implant. The number of implants will vary by patient due to the unique characteristics of the prostate and prostatic urethra.
Multiple Procedure Discount Rule: As a rule, add-on CPT codes, including CPT code 52442, are not subject to the multiple procedure discount rule. The multiple procedure payment
Zero Day Global: CPT codes 52441 and 52442 have been assigned a
Medically Unlikely Edit
It is not uncommon for CMS/Medicare to assign a national medically unlikely edit (MUE) to some CPT codes. Medicare has assigned an MUE of 1 to CPT code 52441 and an MUE of 6 to CPT code 52442. Because CPT code 52442 must always be billed with CPT code 52441, the current maximum number of payable implants (units) under Medicare guidelines is 7. Claims with medically necessary implants in excess of an MUE may require a modifier and/or appeal for processing. Verify MUE requirements with each of your payers. If needed, sample appeal letters are available in the Support Documents section of this website.
Medicare Facility Coding - Hospital Outpatient or Ambulatory Surgery Center (ASC)
† Hospital Outpatient Status indicator:
J1: Comprehensive APC, Payment for all adjunctive services reported on the same claim is packaged into payment for the primary service.
†† ASC Status indicator:
J8: Device-intensive procedure; paid at adjusted rate
A Critical Access Hospital (CAH) is subject to conditions of participation (COP) different than hospitals who participate in IPPS and OPPS. Coding instructions vary depending on COP by facility designation assigned from CMS. It is the responsibility of the facility to understand and comply with appropriate facility coding.
All rates are national, unadjusted Medicare allowed amounts and are subject to geographic adjustments. An "allowed" amount is the maximum allowance for a Medicare covered service, actual payment will vary based on patient co-pay, deductible, etc. Rates referenced in this guide do not reflect sequestration adjustments which are automatic reductions in federal spending that will result in a 2% across-the-board reduction to all Medicare rates as of April 1,2013. Quoted rates also do not reflect payment adjustments related to quality of and/or meaningful use.
Device Intensive: Medicare designated both the Prostatic Urethral Lift procedure HCPCS codes device intensive which requires that hospital claims not only report the most appropriate HCPCS code for the procedure, but also
Non-Medicare: Some non-Medicare payers do not recognize HCPCS codes developed by CMS. It is recommended that you verify with each payer their coding requirements for outpatient facility claims. If CPT codes are recommended, CPT code 52441 will always be reported as only one unit while add-on CPT code 52442 may require multiple units be billed to report the exact number of additional implants used.
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Disclaimer: The information contained in this document was obtained from third-party sources, may not be all-inclusive and is subject to change without notice. Content is informational only and does not constitute medical, legal or reimbursement advice and represents no statement, promise or guarantee of payment. The provider is solely responsible for determining appropriate treatment for the patient based on the unique medical needs of each patient and the independent judgment of the provider. It is also the responsibility of the provider to determine payer appropriate coding, medical necessity, site of service, documentation requirements and payment levels and to submit appropriate codes, modifiers and charges for services rendered. Although we have made every effort to provide information that is current at the time of its issue, it is recommended that you consult your legal counsel, reimbursement/compliance advisor and/or payer organization(s) for interpretation of payer-specific coding, coverage and payment expectations.
NeoTract, Inc. encourages providers to submit claims for services that are appropriately and accurately consistent with FDA clearance and approved labeling and does not promote the use of its products outside their FDA-approved labeling.
Medicare provides a publicly available Physician Fee Schedule at www.cms.hhs.gov. Payment levels are adjusted geographically across the country. Check with your local Medicare carrier for your specific Medicare payment level.
Non-Medicare/commercial health plans likely have proprietary fee schedules that may be based on a % of Medicare rates or negotiated contracts.
Medicare provides a publicly available Hospital Outpatient (OPPS) and ASC Fee Schedule on their website at www.cms.hhs.gov. Please refer to our Commonly Billed Codes section of this website, or the Commonly Billed Codes PDF for national unadjusted Medicare Hospital Outpatient and Ambulatory Surgery Center payment levels. Please verify your specific payment levels with your local Medicare carrier.
It will be at the discretion of the individual health plan whether they will require CPT or HCPCS codes for hospital outpatient or Ambulatory Surgery Center UroLift System claims. Whether billing CPT or HCPCS codes, Non-Medicare/commercial health plans have proprietary facility fee schedules that may be based on a % of Medicare rates or negotiated contracts.
Whether you receive a prior authorization denial, claim denial or insufficient payment, you have the right to appeal on behalf of your patient. The appeal process ensures that critical patient treatment decisions are given appropriate consideration. When appealing, please refer to and follow the health plan’s defined appeal process.
Denials may be the result of the health plan not fully understanding the technology of the UroLift System treatment. Providing additional information to the health plan may be helpful toward overturning a denial. The health plan will review a variety of information, including medical records, published data and society support. Always submit your appeal in accordance with the health plan’s appeal timeline and process.
For your convenience, sample appeal letters are available in the Support Documents section.
For additional guidance contact the NeoTract, Inc. Reimbursement Team at 844-516-5966 or by email at email@example.com.