HIFU Prostate Services 55880

Quest ion:

This is a new elective procedure we would like to start performing. Can you review if this procedure can be charged out on a case level basis like we do for all the other main OR procedures?

Billing codes and reimbursement -- HIFU 55880, aspiration of bladder / SP cath 51102, foley cath 51702, some (but not all) will require cysto 52000 and/or transurethral resection of the prostate (TURP) 52601

Here is some information from the vendor: We mobilize our Sonablate HIFU technology with experienced technicians and FDA mandated disposables on a per-click basis making it possible for hospitals like yours to integrate HIFU (for localized prostate cancer) without the capital purchase of equipment and service contracts.

With the recent change in reimbursement, we are seeking to transition all our nationwide cases to hospitals in 2023 CMSannounced the 2023 OPPSPreliminary Rates recently and reassigned HIFU (55880; Abltj mal prst8 tiss hifu) to Level 6 which reimburses at $8,711 09 (and close to $10,700 in this market). Additionally, we have been told by the hospitals we are already working with that they are receiving reimbursement from commercial carriers already.

What should we expect to get reimbursed from this procedure?

Answ er:

Medicare covers CPT® 55880, OPPSreimbursement for your facility would amount to a total allowed of $9,978.76:

Yes, the hospital surgery department may use one of its time- and acuity-based surgical ?level? charges. The level charge selected should take into account the extra expense incurred for the HIFU equipment vendor. It is inappropriate to charge separate supply charges for re-usable equipment, even if it is rented ? that expense should be captured within the charges for the use of the operating room

Alternately, if the duration of this procedure is fairly predictable, the hospital could opt to create a special hard-coded charge for 55880 In general, we recommend using ?level?charges

Level charges should take into consideration three factors:

- Surgery suite set-up time

- The number of hospital staff required to attend the procedure (excluding professionals that bill separately for their services), and

- Special equipment required

Please note that there are a number of CCI edits that will prevent reporting all of the codes mentioned in your question for the same encounter Some of the code pairs are not billable on the same claim, and no modifier will permit it

If both the ablation and a TURPare performed in the same session, the ablation code 55880 will require a modifier indicating that it is separate and distinct from a TURP52601:

Ultrasound Documentation Requirements

Ultrasound Documentation Requirements: CompletevsLimited

Int roduct ion

Many facilities bill diagnostic ultrasound services from the referring physician?s order as an automated process, without any review by a coding professional This practice is discouraged because when charging for complete diagnostic ultrasounds, the CPT® Manual outlines very specific documentation requirements for these examinations.

The radiology report serves as the documentation for both the professional and technical portions of the examination The documentation within the medical record must support the exam that was performed--both for the professional fee (the radiologist?s interpretation) and the technical fee (the technologist?s work of performing the exam).

It is the reading radiologist?s responsibility to ensure the components of each diagnostic ultrasound exam performed are documented appropriately in the radiology report. The CPT® guidelines for diagnostic ultrasound state that all diagnostic ultrasound studies require the following:

- Permanently recorded images with measurements (when such measurements are clinically indicated)

- A final, written report to be issued for inclusion in the patient?s medical record

Per CPT® , ?Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.?

Com plet e vs Lim it ed Ult rasound

CPT® instructions pertaining to coding a complete vs. a limited ultrasound are as follows: ?For those anatomic regions that have ?complete?and ?limited?ultrasound codes, note the elements that comprise a ?complete?exam The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent).

If less than the required elements for a ?complete?exam are reported (eg, limited number of organs or limited portion of region evaluated), the ?limited?code for that anatomic region should be used once per patient exam session A ?limited?exam of an anatomic region should not be reported for the same exam session as a ?complete?exam of that same region ?