Ryan J. Malone, MD

Mark N. Painter, CPMA, managing partner of PRS Consulting LLC, the CEO of PRS Urology Service Corporation, the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc., and CEO of Relative Value Studies, Inc., discusses changes to Medicare billing in 2021, covering HIFU (high intensity-focused ultrasound) and detailing how the procedure is reimbursed. He details how the new CPT code for 2021, code 55880, is used for ablation of malignant prostate tissue, transretally approached, using high intensity-focused ultrasound (HIFU) and ultrasound guidance. Mr. Painter details how Medicare has set up facility payments: HIFU can only be billed once per date of service, and many Medicare carriers still consider HIFU as a non-covered service. Also, if the HIFU is done at a non-participating facility, it becomes patient responsibility. The new code does not allow for co-surgeons or assistant surgeons. He points out that there is an established fee schedule for facilities and appropriate values for the code, and advises to look at coverage rules and to keep an eye on individual carriers to see whether they will follow NGS moving forward or not. Mr. Painter also advises to check with each payer before providing this service to find where coverage is, where patient responsibilities lie, and to juggle that with your charges and reimbursement activity.