Learn How to Approach Prostatectomy Coding – Part 1
Learn the difference between subtotal and radical procedures. As a urology coder, you should be aware that select codes only apply to certain patients that enter a urology practice. Prostatectomies are procedures that have gender-specific coding rules, and it’s important to understand the different approaches to each surgery to ensure your claims are accurate. This is the first article in a three-part series describing the different types of prostatectomies. Read on to learn about subtotal and radical prostatectomy procedures with perineal approach. What Is a Prostatectomy Procedure? The prostate is a walnut-sized gland located under the bladder and next to the rectum of people assigned male at birth (AMAB). It surrounds the urethra, which is a tube that transports urine from the bladder and through the penis. The prostate plays an important role in sexual reproduction. It helps make semen, the fluid that carries sperm out of the penis — via the urethra — during ejaculation. A urologist performs a prostatectomy procedure to remove all or part of the prostate to treat prostate cancer or to remove part of the prostate to treat benign prostatic hyperplasia (BPH). Two different types of prostatectomies exist: simple or radical. A physician performs a simple prostatectomy to treat BPH where part of the prostate gland is removed. Another surgical option available for BPH, among others, is a transurethral resection of the prostate (TURP). A radical prostatectomy is the removal of the entire prostate, and urologists can use four types of the procedure to treat organ-confined prostate cancer (PCa): A common surgical approach to prostatectomy includes making a larger surgical incision and removing the prostate gland through the incision. Perineal and retropubic prostatectomies are considered open procedures, whereas laparoscopic or robot-assisted prostatectomies are performed through smaller incisions where the laparoscope removes the prostate. The latter do not require a larger surgical opening of the patient. Perineal prostatectomy, which is performed through the perineum, is used less frequently than the retropubic approach (through the abdomen). However, the perineal procedure takes less time and may be an option if the nerve-sparing approach isn’t needed. A surgeon may use a perineal prostatectomy if other medical conditions rule out performing a retropubic approach, such as numerous abdominal surgeries, obesity, previous pelvic arterial bypass grafts, or a patient with a delayed recurrence of prostate cancer after salvage prostatectomy and radiotherapy. Pinpoint What’s Involved in a Perineal Prostatectomy A surgeon performs the perineal prostatectomy by making an incision in the perineum, which is the skin between the scrotum and the rectum. The CPT® code set contains multiple codes to report perineal subtotal and perineal radical prostatectomy alone, with lymph node biopsy, and with removal of lymph nodes. Review the code entries below: During a subtotal prostatectomy using the perineal approach (55801), the surgeon makes an inverted U-shaped incision in the perineum. After isolating the rectum from the prostate toward the back, the provider examines the area and excises part of the prostate. They take care around the seminal vesicles and excise the vas deferens. The surgeon also inserts a catheter, or tube, with a small balloon at its end into the urethra to enlarge the opening and ensure adequate urinary flow. The provider then places a drainage catheter in the urinary bladder to allow urine to pass and monitor postoperative bleeding while the patient heals. A subtotal prostatectomy is also known as a partial prostatectomy since only a portion of the prostate is removed, not the entire gland. Assign 55810 when the surgeon performs a radical prostatectomy via the perineal approach. During the procedure, the provider makes an inverted U-shaped incision in the perineum where they separate the rectum from the rear of the prostate. In addition to excising the entire prostate gland, the provider removes the patient’s vas deferens and the seminal vesicles. The surgeon removes additional tissue to achieve a clear margin of health tissue. For a radical prostatectomy with lymph node biopsies performed via the perineal approach, you’ll assign 55812. This procedure is similar to the radical prostatectomy described above, with the difference being that the surgeon also excises the pelvic lymph nodes. The provider then submits the specimens to a laboratory for analysis. Report 55815 when the provider excises the patient’s prostate, vas deferens, seminal vesicles, and pelvic lymph nodes, which include the external iliac, hypogastric, and obturator lymph nodes. Remember This Expert Documentation Advice It is important to review the surgical report to determine which procedure was performed on the patient. If the documentation is not clear, create a dialogue with the provider who performed the procedure to make sure the appropriate CPT® code is reported. Stay tuned for the next part in the series when Revenue Cycle Insider will focus on open prostatectomies. Stephanie N. Stinchcomb Storck, CPC, CPMA, CUC, CCS-P,
longtime urology coding expert, Summerfield, Florida
