On August 27, 2015, the FDA cleared for marketing the Rezum System to relieve lower urinary tract symptoms secondary to benign prostatic hyperplasia. This procedure involves the transurethral injection of steam into the prostate. Once injected, the steam condenses to water, imparting convective energy to the tissue, causing cell death and damage. The technology uses radiofrequency (RF) to boil the water to create the steam that is injected, but does not impart radiofrequency directly to the prostate tissue.
Rezum received FDA 510(k) clearance on February 27, 2018. Available evidence has shown that the Rezum procedure for treatment of BPH is reasonable and necessary. The procedure is covered for FDA approved indications if the appropriate criteria are met.
For Medicare Billing: Hospital Outpatient Setting or Ambulatory Surgical Center:
- Effective January 1, 2019, claims billed for procedures involving Rezum should be coded as CPT 53854.
- Documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450 form) or the equivalent 5010 electronic claims
Physician’s Office:
- Effective January 1, 2019 claims billed for procedures involving Rezum should be coded as CPT 53854.
- Documentation must be included in Box 19 on the CMS 1500 form or the electronic equivalent to indicate that the Rezum procedure was performed.
NOTE: Claims for procedures involving Rezum steam injection should NOT be coded as CPT 53852 because the technology does not apply radiofrequency energy to the prostate. Prostatic tissue destruction is accomplished via steam generated by RF, not by the RF itself.
Sources of Information:
1. McVary KT, Gange SN, Gittelman MC, et al. Erectile and Ejaculatory Function Preserved With Convective Water Vapor Energy Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Randomized Controlled Study. J Sex Med. 2016;13(6):924-933.
2. McVary KT, Gange SN, Gittelman MC, et al. Minimally Invasive Prostate Convective Water Vapor Energy Ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. J Urol. 2016;195(5):1529-1538.
3. Dixon CM, Rijo Cedano E, Pacik D, et al. Efficacy and Safety of Rezum System Water Vapor Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Urology. 2015;86(5):1042-1047.
4. Mynderse LA, Hanson D, Robb RA, et al. Rezum System Water Vapor Treatment for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: Validation of Convective Thermal Energy Transfer and Characterization With Magnetic Resonance Imaging and 3-Dimensional Renderings. Urology. 2015;86(1):122-127.
5. Dixon CM, Rijo Cedano E, Pacik D, et al. Two-year results after convective radiofrequency water vapor thermal therapy of symptomatic benign prostatic hyperplasia. Research and Reports in Urology. 2016;8:207–216.
