Learn How to Approach Prostatectomy Coding – Part 2
Does a prostatectomy code require a modifier for a biopsy? In the first article of this three-part series, Revenue Cycle Insider covered prostatectomies with a perineal approach. Again, 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 second article in the series, which describes the different types of prostatectomies. Read on to learn about retropubic prostatectomy procedures with an open abdominal approach. What Is a Prostatectomy Procedure? As discussed in the previous article, the prostate is a walnut-sized gland located under the bladder and next to the rectum of people assigned male at birth (AMAB). The gland 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 retropubic radical prostatectomy is removal of the entire prostate through an incision in the abdomen. This approach is in contrast to a perineal prostatectomy, where the urologist removes the prostate through an incision in the perineum (the area between the rectum and the scrotum. In this article, we are discussing prostatectomy using an open, retropubic approach (incision in the abdomen) for prostate cancer. Realize What a Retropubic Prostatectomy Includes A surgeon performs a retropubic prostatectomy by making an incision in the lower abdomen, between the belly button and pubic bone, to access and remove the prostate gland and sometimes surrounding tissues like the seminal vesicles and lymph nodes. The CPT® code book features multiple codes to report retropubic radical prostatectomy alone, with lymph node biopsies, and removal of lymph nodes. Review the retropubic radical prostatectomy code entries below: During a retropubic radical prostatectomy (55840), the surgeon makes a midline incision in the lower abdominal area. This incision is extended through the fascia, muscles, and down to the bladder. The bladder is freed. If necessary, the provider may also remove the neurovascular bundles. The prostate is then delivered off the bladder by incising and using a clip-and-suture ligature on the vascular pedicles and incising over the seminal vesicles and incising and clipping the ejaculatory ducts and seminal vesicles. The bladder neck is then dissected free from the prostate. Anastomosis of the bladder to the urethra is performed. An autologous fascial sling may be created by cutting a strip of rectus fascia and placing it underneath the anastomosis with an angled clamp. Finally, the incisions are closed. The code also includes the possibility of trying to avoid damaging the nerves that control erectile function, but this is not always possible or appropriate. Report 55840 regardless of whether the surgeon takes nerve-sparing precautions. Assign 55842 when the provider performs a radical retropubic prostatectomy as described above, collects lymph node biopsies around the prostate, and submits the samples for pathologic diagnosis. The base procedure is the same as 55840. Sometimes, the surgeon must perform a lymphadenectomy to remove all the lymph nodes including the external iliac, hypogastric, and obturator nodes around the prostate during the retropubic radical prostatectomy procedure. Use 55845 to report this procedure. The code descriptor includes three lymph node areas, but if only two of the three nodes are removed, it is not necessary to append modifier 52 (Reduced services) to indicate certain lymph nodes were removed. Pay Attention to This Documentation Advice It is important to review the surgical report to determine which procedure was performed on the patient. If the documentation is unclear, create a dialogue with the provider who performed the procedure to make sure you report the appropriate CPT® code. In the final part of the series, Revenue Cycle Insider will focus on laparoscopic and robotic-assisted prostatectomies. Stephanie N. Stinchcomb Storck, CPC, CPMA, CUC, CCS-P,
longtime urology coding expert, Summerfield, Florida
