Transcript Slide 1

Reimbursement Overview
Calendar Year 2008
Outline for Today
• Overview of Benign Prostatic Hyperplasia (BPH)
• PROSTIVA® RF Therapy
• Coverage and Coding for PROSTIVA
• Physician Reimbursement
• Hospital Outpatient Reimbursement
• Ambulatory Surgery Center (ASC) Reimbursement
Overview of BPH
Symptomatic BPH Population
US Prevalence: 14.9 Million
US Incidence:
500,000
Translates to:
50% of men over 50
60% of men over 60
70% of men over 70
80% of men over 80
US Census; Millennium Research, 2006; A.G. Edwards & Son, 2006.
Overview of BPH
Prostate Enlargement
• The prostate goes through two periods of growth.
The first occurs early in puberty when the prostate
doubles in size.
• At around age 25, the prostate begins to grow
again and often results, years later, in a condition
called an enlarged prostate.
• The medical term for this condition is called Benign
Prostatic Hyperplasia (BPH).
Overview of BPH
BPH Defined
• BPH is the most common nonmalignant disorder of the
prostate and is characterized by prostatic
enlargement, obstruction of the bladder outlet, and
voiding symptoms.
• BPH is also referred to as Benign Prostatic
Hypertrophy
– Hyperplasia describes the process where cells increase in
numbers
– Hypertrophy describes the increase in cell size
– Hyperplasia is the predominant process
Overview of BPH
How Does BPH Affect Urination?
• BPH is a non-cancerous enlargement of the prostate
• As the prostate enlarges, it presses against the urethra like a
clamp on a garden hose
• This can obstruct the flow of urine through the urethra
Overview of BPH
How Does BPH Affect Urination?
• The bladder wall becomes thicker and irritable
and begins to contract even when it contains a
small amount of urine.
• These contractions cause the bladder to
weaken so it does not completely empty.
Overview of BPH
Why Treat BPH?
• BPH is not cancer but it can lead to unwanted
complications if not corrected
• Urine retention and strain on the bladder can lead to
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Urinary tract infections
Bladder or kidney damage
Bladder stones
Incontinence
• When BPH is diagnosed and treated early, there is a
lower risk of developing such complications
PROSTIVA® RF Therapy
• Safe and effective
• A single office visit, treatment of
less than one hour
• Fewer side effects and adverse
events when compared to
traditional surgical treatments
• Covered by Medicare and
Medicaid in all 50 states and
many private insurance
companies
PROSTIVA® RF Therapy
• Delivers low-level radio frequency
energy into the middle of the
prostate and relieves obstruction
without causing damage to the
urethra
• Can be performed with a sedative
and local anesthetic in a urologist’s
office
• Procedure takes less than one hour
• Catheterization, if required, is zerotwo days on average
• Intended for men over age 50
PROSTIVA® RF Therapy
Indication for Use
PROSTIVA® radio frequency therapy is
indicated for the treatment of symptoms
due to urinary outflow obstruction
secondary to benign prostatic hyperplasia
(BPH) in men over the age of 50 with
prostate sizes between 20 and 50 cm3.
PROSTIVA® RF Therapy System User Guide.
Disclaimer
Medtronic has compiled this coding information for your convenience. It
is always the provider’s responsibility to determine coverage and
submit appropriate codes, modifiers, and charges for the services that
were rendered. Contact your local carrier/payor for interpretation of
appropriate coverage and coding policies. For unapproved uses,
consult with your local carrier/payor before seeking reimbursement for
use of a product that may be inconsistent with or not expressly
specified in the FDA cleared or approved labeling (manual). Some
payors may have policies that make it inappropriate to submit claims for
such items or related services.
Coverage and Coding
Coverage for PROSTIVA – Applicable Policies
• There is currently no National Coverage Determination
(NCD) for PROSTIVA/TUNA*; however many states
have local policies.
• The CPT code for PROSTIVA (53852) is on the Medicare
Fee Schedules for 2008 (Physician, Hospital Outpatient,
and ASC).
• Many commercial payors have written coverage policy
for PROSTIVA/TUNA*
Providers should refer to the applicable coverage policy!
*Note: Most policies for PROSTIVA will be listed under “TUNA.”
Coverage and Coding
Coverage for PROSTIVA – Diagnosis Coding
• CMS requires 5 digit ICD-9 Diagnosis Codes
• See our PROSTIVA reimbursement guide for common
diagnosis codes.
Providers should refer to the applicable coverage policy for diagnosis
coding!
Coverage and Coding
Coverage for PROSTIVA - Typical LCD Language
Indications must be documented (vary by state)
– BPH of Significant Degree to Cause
• An AUA symptom score of 11 or higher
• Urine flow rate of 15 cc/sec. or less on a voided volume of 125 cc or
more
• Volume of the prostate less than 65 gms on a transrectal ultrasound
of the prostate
• Failed trial of voiding with an alpha-blocker medication, or tolerance
to alpha- blocker
Coverage and Coding
Coverage for PROSTIVA - Typical LCD Language
Common contraindications may include:
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Prostate or Bladder Cancer
Neurogenic, decompensated or atonic bladder
Prior non-drug treatment (eg TURP, Laser, TUMT)
Presence of other device that could interfere, eg penile implant,
pacemaker, ICD, neurostimulator
Prostate size less than 34 mm or greater than 80 mm tranverse
diameter
Active cystolithiasis, gross hematuria, urethral stricture acute prostatitis,
diabetes mellitis affecting bladder function
Active urinary tract infection
ASA class group V patients
Providers should refer to the applicable coverage policy for medical
necessity criteria!
Coverage and Coding
Coding for PROSTIVA
The CPT Code for
PROSTIVA is:
53852
CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT)
is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use.
Coverage and Coding
Coding for PROSTIVA
53852 - Transurethral destruction of
prostate tissue; by radio frequency
thermotherapy
CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT)
is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use.
Coverage and Coding
Coding for PROSTIVA
“Workup” codes for PROSTIVA commonly include:
– Office Visit (CPT Codes 99201-99205 or 99211-99215)
– Electro-Uroflowmetry (CPT Code 51741)
– Cystoscopy (CPT Code 52000)
– PSA (CPT Code 84153)
– Urinalysis (CPT Code 81000–81003)
– Office or Other Outpatient Consultation (New or Established Patient) (CPT
Codes 99241-99245)
CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT)
is copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use.
Physician Reimbursement
Physician Reimbursement: January – June 2008
• 53852 Non-Facility (Office) Rate: $2,959*
• 53852 Facility (Hospital or ASC) Rate: $595*
• The Non-Facility Rate is designed to cover the cost of
the physician’s time, the disposable cartridge and any
additional indirect expense (rent, nursing staff, etc.)
• This code has a 90-day global period.
*Indicates national average payment amount from Medicare – commercial payor
reimbursement will be based on the provider’s individual contract with that payor.
Physician Reimbursement
Physician Reimbursement: January – June 2008
A Note on Global Periods:
• The global period describes the time interval for all related services
and care included in a surgical procedure
• PROSTIVA Therapy – CPT 53852 – has a global period of 90 days
• The global period for PROSTIVA Therapy is inclusive of anesthetics,
whether lidocaine or the use of a prostatic block
Examples:
• PROSTIVA patient returns to office after three days for catheter
removal – can the physician bill for an office visit? NO
• PROSTIVA patient sees the physician within the 90 days for
continued concerns about their BPH, or for questions about the
PROSTIVA procedure – can the physician bill for an office visit? NO
Hospital Outpatient Reimbursement
Hospital Outpatient Reimbursement: 2008
• In 2008, CPT code maps to APC 0429 in the Medicare
Outpatient Prospective Payment System (OPPS).
• APC 0429 has a national average payment rate of
$2,879*
• There is no separate device code for the disposable
PROSTIVA cartridge.
*Indicates national average payment amount from Medicare – commercial payor
reimbursement will be based on the provider’s individual contract with that payor.
ASC Reimbursement
Ambulatory Surgery Center (ASC) Reimbursement: 2008
• In 2008, CPT code maps to APC 0429 in the Medicare’s
ASC Payment System.
• APC 0429 has a national average payment rate of
$1,872* in an ASC setting
• There is no separate device code for the disposable
PROSTIVA cartridge.
*Indicates national average payment amount from Medicare – commercial payor
reimbursement will be based on the provider’s individual contract with that payor.
PROSTIVA Reimbursement
• What is a modifier?
– A modifier is used with CPT codes to denote special
consideration on the code
– PROSTIVA CPT Code is 53852
• Two modifiers that are commonly associated with PROSTIVA are:
– -53 Discontinued Procedure
• Example: PROSTIVA procedure was aborted partial way
through
– -59 Distinct Procedural Service
• Example: TRUS was performed on the same day as
PROSTIVA
PROSTIVA Reimbursement
Questions????
PROSTIVA® RF Therapy
Indications: PROSTIVA RF Therapy is indicated for the treatment of
symptoms due to urinary outflow obstruction secondary to benign
prostatic hyperplasia (BPH) in men over the age of 50 with prostate
sizes between 20 and 50 cc.
Adverse Events: Side effects may include obstruction, urinary
retention, bleeding, pain/discomfort, urgency, frequency and urinary
tract infection.
CAUTION: Federal law (USA) restricts this device to sale by or on the
order of a physician. For a listing of indications, contraindications,
precautions and warnings, please refer to the System User Guide.