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Commonly Billed Codes

It is the provider’s responsibility to select the most specific codes to report a patient’s condition and services rendered. The following may provide applicable coding information for the UroLift® System treatment. Some payers may have unique coding requirements; please verify coding with the health plan.

Diagnosis Coding

The UroLift System is indicated for the treatment of symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH) in men age 45 and above. Listed is the most common ICD-10 BPH diagnosis code which may be appropriate based on the patient’s condition(s) and history.

Diagnosis Coding

Physician Coding and Medicare Payment Information

Click here for Commonly Billed Codes

*CY2018 Conversion Factor: $35.9996.
t – Physician payment will vary by SOS and geographic adjustments.
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 and/or meaningful use.

Using add-on codes: CPT code 52441 is used to report the initial implant and add-on CPT code 52442 reports each additional implant. The number of implants will vary due to the unique characteristics of the prostate and prostatic urethra, but clinical data supports an average of 4-5 implants per procedure.

Multiple Procedure Discount Rule: Because CPT code 52442 is designated an add-on code, it is not subject to the multiple procedure discount rule. The multiple procedure payment reduction may however apply to the primary CPT code 52441 if additional surgical procedures are done on the same day.

Zero Day Global: CPT codes 52441 and 52442 have been assigned a zero day global period which allows for all related post procedure visits and services to be separately billed and reimbursed when medically necessary.

Medically Unlikely Edit

CMS/Medicare has imposed a national medically unlikely edit (MUE) on CPT code 52442 which limits the number of payable units to 6. Because CPT code 52442 must always be billed with CPT code 52441, the maximum number of payable units is 7. To be considered for payment, a modifier may be necessary to report medically reasonable and necessary units of CPT code 52442 in excess of the MUE. Although there are several available modifiers, modifier -76 appears to be the most appropriate based on description. Please verify with your Medicare carrier the appropriate use of modifiers under an MUE (It is unlikely the use of a modifier will be required for non-Medicare, commercial insurance plans).

Denied implants in excess of the MUE can be appealed with medical justification.

Facility Hospital Outpatient or Ambulatory Surgery Center (ASC)

1 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.
2 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.

*Device Intensive: Medicare designated both the UroLift System HCPCS codes device intensive which requires that hospital claims not only report the appropriate CPT code for the procedure, but also a HCPCS device code for each implant delivered. Currently CMS/Medicare recommends that L8699 be used to report and price each implant delivered. Reporting HCPCS code L8699 will not receive additional Medicare reimbursement, but it will help ensure claims are not rejected for being incomplete. Reporting L8699 with appropriate charges based on your unique CCR will also help to protect future APC assignment and rate setting. Commercial payers may process L8699 separately for payment.

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 preference 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 based on the number of additional implants used.

CPT© codes and descriptions are copyright 2018 American Medical Association (AMA).
All rights reserved.
CPT© is a registered trademark of the AMA.

Prior Authorization

Medicare

The Medicare program does not require prior authorization for the UroLift System treatment.

Commercial Health Plans & Medicare Advantage

Prior authorization for treatment is recommended for all UroLift System treatments. Please contact the health plan to understand their prior authorization requirements before initiating treatment.

To assist you in the prior authorization process, NeoTract, Inc. has created a prior authorization flow chart and sample letters of medical necessity. These letters will provide an understanding of the type of information that may be required by health plans to rule favorably on a UroLift System prior authorization. The flow chart and sample letters are available in the Support Documents section. 

Prior Authorization Denials

The UroLift System prior authorization may be denied because the payer does not yet have enough information to make a favorable decision. You have the right to appeal a denied prior authorization. Consult with the specific health plan for their appeal process.

NeoTract, Inc. has created sample appeal letters that will guide you in the development of an appeal letter. The letter and other supporting documentation can be found in the Support Documents section.

For additional guidance contact the NeoTract, Inc. Reimbursement Team at 844-516-5966 or by email at uroliftreimbursement@teleflex.com.  

 

Coverage & Payment

Coverage

Medicare across the country is routinely covering the UroLift System treatment and the treatment continues to gain favorable commercial coverage.

For a list of coverage please see the Support Documents section. This list may not be all inclusive. Please verify coverage with the individual health plan or check with the NeoTract, Inc. Reimbursement Team to learn more about the health plans important to you.   

Payment

Physician

Medicare has an established Physician Fee Schedule; payment levels are adjusted geographically across the country. Please check with your local Medicare carrier for your specific Medicare payment level.

Non-Medicare/commercial health plans may pay at a % of Medicare or rely on negotiated contracts to establish payment levels. When negotiating a contracted rate or submitting a UroLift System claim for an office-based treatment, be sure to factor in applicable professional services, practice expense, and the cost of the UroLift implant(s).

Facility

Medicare

Please refer to the 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.

Non-Medicare

It will be at the discretion of the individual health plan whether they will require CPT codes or HCPCS codes for hospital outpatient or Ambulatory Surgery Center UroLift System claims. Please verify appropriate coding with the health plan. Non-Medicare reimbursement levels may be calculated based on a percentage of the Medicare hospital outpatient fee schedule, ASC fee schedule or negotiated contracts.

Denials & Appeals

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 or the UroLift System treatment. The most effective way to address this issue and establish coverage for a treatment is through the appeals process.

Providing additional information to the health plan may be helpful toward overturning a denial. In instances where the health plan has denied the UroLift System treatment, it is important to include the appropriate information in your appeal packet. The health plan will review a variety of information, including medical records, published data and society support.

The appeal letter should request the health plan reconsider the denial and authorize coverage and payment for the medically necessary, clinically supported and FDA cleared UroLift System treatment. 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 uroliftreimbursement@teleflex.com

Support Documents

Sample Letters

Key Clinical Information

UroLift® Billing Guides

Society Support

FDA Documentation

Coverage

Medicare

  • Medicare across the country routinely covers the UroLift System treatment. 

Commercial Plans

In addition to the coverage listed specific to your state, there are numerous out of state BCBS plans that have a positive medical policy for the UroLift System. If you see patients covered by a BCBS plan outside of your state, we recommend you verify coverage and benefits directly with the out of state BCBS plan. The NeoTract, Inc. Reimbursement Team may also have additional information about BCBS coverage across the country.

Please select your state to view the coverage list.

    Disclaimer: NeoTract, Inc. has compiled this coding information from third party sources and is subject to change without notice. This information is presented for illustrative purposes only and does not constitute legal or reimbursement advice.  This information is not a guarantee of payment.  It is always the provider’s responsibility to determine medical necessity and appropriate site of service, and submit appropriate codes, modifiers and charges for services rendered. Please contact your local payer/carrier and/or legal counsel for interpretation of coding and coverage.

    CPT© codes and descriptions are copyright 2018 American Medical Association (AMA).
    All rights reserved.
    CPT© is a registered trademark of the AMA.

    Frequently Asked Questions