How To Use CPT Code 53854

CPT 53854 describes the transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53854?

CPT 53854 is used to describe a procedure in which a radiofrequency-generated water vapor thermal device is used to destroy prostate tissue. This procedure is typically performed to treat benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. It involves the insertion of a proprietary RF-heated water vapor delivery device into the urethra, under direct cystoscopic visualization. The provider then delivers RF-generated water vapor into the prostate, targeting the transition zone between the bladder neck and the prostate. The goal is to destroy enough prostatic tissue to alleviate symptoms and improve urinary flow.

2. Official Description

The official description of CPT code 53854 is: ‘Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy.’

3. Procedure

1. The patient is appropriately prepped and anesthetized or sedated and placed in the lithotomy position.
2. The provider inserts the RF-heated water vapor delivery device into the urethra, under direct cystoscopic visualization.
3. The provider positions the needle tip of the device distal to the bladder neck and targets the transition zone between the bladder neck and the prostate.
4. The provider injects RF-generated water vapor into the prostate, 1 cm from the proximal edge of where the lateral and medial lobes protrude into the bladder.
5. The provider delivers the RF-generated water vapor in 9-second bursts circumferentially to the prostate, retracting the needle after each injection and repositioning it 1 cm distal to the previous site.
6. The provider repeats these injections until reaching the prostatic tissue just proximal to the verumontanum, creating contiguous and overlapping zones parallel to the natural angle of the urethra.
7. The total number of treatments varies depending on the size and shape of the prostate.
8. Once enough prostatic tissue has been destroyed, the provider withdraws the instrument.

4. Qualifying circumstances

CPT 53854 is typically performed on patients with benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate gland that can compress the flow of urine. The procedure is intended to alleviate lower urinary tract symptoms associated with BPH. It is important to note that payer policies may consider this procedure investigational, so it is advisable to check with the payer regarding their payment policies before performing the procedure.

5. When to use CPT code 53854

CPT code 53854 should be used when a provider performs transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy. It is important to ensure that the procedure is performed for the treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. If the procedure is performed for other indications, a different CPT code may be more appropriate.

6. Documentation requirements

To support a claim for CPT code 53854, the provider must document the following information:

• Patient’s diagnosis of benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms
• Details of the procedure, including the use of the RF-heated water vapor delivery device
• Date and duration of the procedure
• Specific steps taken during the procedure, such as needle placement and delivery of RF-generated water vapor
• Progress made during the procedure, including the amount of prostatic tissue destroyed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 53854, it is important to ensure that the procedure is performed using a radiofrequency-generated water vapor thermal device. The procedure should be documented appropriately, and the necessary documentation should be submitted with the claim. It is also important to check with the payer regarding their policies on payment for this procedure, as it may be considered investigational by some payers.

8. Historical information

CPT code 53854 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Examples

1. A 65-year-old male with benign prostatic hyperplasia (BPH) undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to alleviate his lower urinary tract symptoms.
2. A 70-year-old male with BPH and urinary retention undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to improve his urinary flow.
3. A 60-year-old male with BPH and recurrent urinary tract infections undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to reduce his risk of infection.
4. A 75-year-old male with BPH and bladder stones undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to alleviate his symptoms and facilitate the removal of the stones.
5. A 55-year-old male with BPH and urinary incontinence undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to improve his bladder control.
6. A 68-year-old male with BPH and hematuria undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to stop the bleeding and alleviate his symptoms.
7. A 72-year-old male with BPH and recurrent urinary tract infections undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to reduce his risk of infection.
8. A 63-year-old male with BPH and urinary retention undergoes transurethral destruction of prostate tissue using radiofrequency-generated water vapor thermotherapy to improve his urinary flow.