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Effective October 1, 2021, Prostate Procedures for Benign Prostatic Hyperplasia Benefit Criteria to Change

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after October 1, 2021, benefit criteria will change for prostate procedures for benign prostatic hyperplasia.

Prostate procedures may be a benefit of Texas Medicaid and include surgical, minimally invasive, and laser procedures. Prostate procedures treat lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH).

Minimally Invasive Therapies (MIST) for BPH

New Benefit—Prostatic Urethral Lift (PUL)

Minimally invasive therapy (MIST) PUL procedure code 52441 is limited to one service per lifetime, same procedure, any provider for male clients ages 45 and older. It may be reimbursed to physician providers in an office or outpatient hospital setting.

PUL procedure code 52442 is limited to six implants per lifetime, any provider, for male clients ages 45 and older. It may be reimbursed to physician providers in the office or outpatient hospital setting. Prior authorization is required if more than 6 total implants are needed.

PUL procedure code 52442 will be denied if it is not billed on the same date of service as procedure code 52441.

PUL procedure codes C9739 and C9740 may be reimbursed for one service per lifetime, same procedure, any provider for clients ages 45 and older. It may be reimbursed to ambulatory surgical center (freestanding, independent, and hospital based) providers for services rendered in the outpatient hospital setting. 

PUL may be billed with only one of the following sets of codes:

  • Procedure codes 52441 and 52442 for services rendered in the office or outpatient hospital setting
  • Procedure codes C9739 for the first through third implant and C9740 for four or more subsequent implants for service rendered in an ambulatory surgical center

New Benefit—Transurethral Needle Ablation (TUNA)

Surgery procedure code 53852 may be reimbursed for one surgical procedure per day, same procedure, same place of service, and different providers as follows:

Type of Service Place of Service Provider Type
Surgery Office Physician assistant, nurse practitioner, clinical nurse specialist, and physician providers
Ambulatory Surgical Center Outpatient Hospital Ambulatory surgical center (freestanding, independent, and hospital based) providers

Surgery procedure code 53852 will not be reimbursed to any provider for services rendered in the inpatient hospital setting or to certified nurse midwife, registered nurse, or licensed midwife providers for services rendered in the outpatient hospital setting.

Holmium Laser Procedures of the Prostate

The following provider types and places of service will be added for procedure code 52649:

Type of Service Place of Service Provider Type
Surgery Outpatient Hospital Physician
Ambulatory Surgical Center Inpatient and Outpatient Hospital Physician assistant, nurse practitioner, clinical nurse specialist, and physician providers

Assistant surgery procedure code 52649 requires prior authorization.

Transurethral Microwave Thermotherapy (TUMT)

The age restriction for procedure code 53850 will be updated to include clients ages 21 and older.

Rezum Water Vapor Therapy

Rezum water vapor therapy procedure code 53854 is limited to male clients ages 21 and older. It will not be reimbursed to any provider type for services rendered in the inpatient hospital setting.

Temporary Urethral Stent

Procedure code 53855 for assistant surgery may be reimbursed for male clients of all ages to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers in office, inpatient hospital, and outpatient hospital settings.

Surgery for BPH

Transurethral Resection of the Prostate (TURP)

Transurethral resection of the prostate (TURP) may be billed with procedure codes 52601, 52630, or 52640.

Procedure codes 52351 or 52354 will be denied if billed with procedure code 52601.

Procedure code 52601 must be billed for the first TURP and may be billed again if the first TURP is staged with modifier 58. Therefore, procedure code 52601 will no longer be limited to one per lifetime, any provider, because a staged procedure with modifier 58 is allowed.

For more information, call the TMHP Contact Center at 800-925-9126.