Does 53854 require prior authorization?

No, 53854 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 53854?

Medicare facility rate: $354.05. Non-facility rate: $3395.54. Work RVU: 5.78.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

5.78

Facility

$354.05

Non-Facility

$3395.54

Hospital outpatient or ambulatory surgical center claims for Rezum must be coded as CPT 53854 and include documentation in the remarks field (Field Locator 80) on the UB-04 (CMS 1450) or equivalent 5010 electronic claim indicating the Rezum procedure was performed.
Physician office claims for Rezum must be coded as CPT 53854 and include documentation in Box 19 on the CMS-1500 form or electronic equivalent indicating the Rezum procedure was performed.
Coding and documentation requirements effective January 1, 2019; ensure electronic claims use the equivalent fields specified (5010 electronic claims).
For transurethral water jet ablation (Aquablation): documentation of LUTS due to BPH and that procedure is for resection/removal of prostate tissue for LUTS/BPH.

Rezum System (convective water vapor thermal therapy) is covered to relieve lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) when used for FDA-cleared indications.
Coverage applies when the procedure meets the FDA-approved indication(s) and any applicable clinical criteria specified by the FDA labeling.
Transurethral ablation of the prostate is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Prostatectomy, Transurethral Ablation.
Cryoablation of the prostate is proven and medically necessary for recurrent prostate cancer diagnosed by biopsy.
Prostatic urethral lift (PUL) is proven and medically necessary when performed according to the following U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions: Treating symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral, with or without median lobe hyperplasia, in men 45 years of age or older.
High-energy water vapor thermotherapy for the treatment of benign prostatic hyperplasia (BPH) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Prostatectomy, Transurethral Ablation.

AETNA-CPB-0079 — Benign Prostatic Hyperplasia

A56083 — Billing and Coding: Rezum System for Benign Prostatic

UHC-POL-prostate-surgery — Prostate Surgeries and Interventions

UMR-POL-UMR-prostate-surgery — Prostate Surgeries and Interventions

SUREST-POL-SUREST-prostate-surgery — Prostate Surgeries and Interventions

Ask Verity about documentation requirements, denial risks, or coverage in your state.