CMS Pub. 100-04, ch. 32, § 180.2

Claims for cryosurgery for the prostate gland are to be submitted on the ASC X12 837, or, in exceptional

circumstances, on a hard copy Form CMS – 1450. This procedure can be rendered in an inpatient or

outpatient hospital setting (types of bill (TOBs) 11x 13x, 83x, and 85x).

The A/B MAC (A) will look for the following when processing claims with cryosurgery services:

• If ICD-9-CM is applicable, ICD-9 CM diagnosis code 185 or

• If ICD-10-CM is applicable, ICD-10 CM diagnosis code C61 must be on all cryosurgical claims;

• For outpatient claims HCPCS 55873 and revenue codes 0360, 0361, or 0369 Cryosurgery ablation of

localized prostate cancer, stages T1- T3 (includes ultrasonic guidance for interstitial cryosurgery probe

placement, postoperative irrigations and aspiration of sloughing tissue included) must be on all

outpatient claims; and

• For inpatient claims correct procedure codes are:

o If ICD-9-CM is applicable, ICD-9-CM procedure code 60.62 (perineal prostatectomy- the

definition includes cryoablation of prostate, cryostatectomy of prostate, and radical

cryosurgical ablation of prostate)

o If ICD-10 is applicable,ICD-10-PCS procedure code 0V500ZZ (Destruction of Prostate, Open

Approach), or 0V503ZZ (Destruction of Prostate, Percutaneous Approach), or 0V504ZZ

(Destruction of Prostate, Percutaneous Endoscopic Approach).