September 30, 2016

Category III Code Set for PeriProstatic Material

Category III code 0438T, Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance, has been established by the CPT Editorial Panel in response to a vendor CPT code proposal for tracking purposes.

The procedure did not demonstrate evidence of widespread utilization necessary to establish a Category I code when it was initially reviewed by the CPT Editorial Panel in October 2015 and, therefore, a Category III code was approved by the panel.

Code 0438T went into effect on July 1, 2016 and replaced the temporary HCPCS C-code C9743, Injection/implantation of bulking or spacer material (any type) with or without imaging guidance. Therefore, the current recommended coding is to report the CPT category III code 0438T to describe the placement of the biodegradable material and A4649, Surgical Supply, miscellaneous, to describe the gel used. Although ultrasound guidance is used to facilitate needle placement, the guidance code is not reported separately, as the 0438T code descriptor specifies “includes image guidance.”

The ACR supports coverage and will work with radiation oncology Carrier Advisory Committee*members to promote coverage by Medicare administrative contractors for this study and gel.

*Medicare has, by statute, an obligation to meet with the representative physicians from the various specialty societies through the Carrier Advisory Committee, better known as the CAC. Meeting quarterly, the CAC serves as the clearinghouse for the discussion of Medicare policy at the carrier level, as well as offering a forum for the free and open discussion of other issues concerning payment and provider education. A very successful program, the CAC network is a valuable and effective venue. (Reference