How To Use CPT Code 55801

CPT 55801 describes the excision procedure on the prostate gland through an incision in the perineum. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 55801?

CPT 55801 is used to describe a surgical excision procedure on the prostate gland. The procedure involves making an incision in the perineum, removing a portion of the prostate gland, and taking measures to prevent postoperative bleeding. It may also include other related procedures such as vasectomy, meatotomy, urethral calibration, and internal urethrotomy.

2. Official Description

The official description of CPT code 55801 is: ‘Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy).’ This code is used to report the excision procedure on the prostate gland performed through an incision in the perineum.

3. Procedure

1. The provider begins by making an inverted U-shaped incision in the perineum.
2. They isolate the rectum from the prostate gland.
3. A portion of the prostate gland is excised, taking care not to harm the seminal vesicles.
4. The vas deferens is excised, which is the duct that carries sperm away from the prostate gland.
5. A catheter with a small balloon is inserted into the urethra to enlarge the opening and ensure adequate urinary flow.
6. If necessary, the provider may incise the urethra or the meatus to further enlarge the urinary opening.
7. A drainage catheter is placed in the urinary bladder to monitor postoperative bleeding and allow urine to pass.
8. The provider irrigates the area, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 55801 is performed to treat a tumor or persistent enlargement of the prostate gland that is obstructing urinary flow. It is important to note that this procedure is performed through an incision in the perineum and is considered a subtotal prostatectomy. The provider may also perform other related procedures such as vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy.

5. When to use CPT code 55801

CPT code 55801 should be used when the provider performs a perineal prostatectomy, subtotal, along with other related procedures such as control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy. It is important to accurately document the specific procedures performed to support the use of this code.

6. Documentation requirements

To support a claim for CPT 55801, the provider must document the following information:

• Reason for the procedure, such as a tumor or persistent enlargement of the prostate gland
• Specific procedures performed, including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy
• Date of the procedure
• Details of the surgical technique used
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 55801, ensure that the procedure performed meets the criteria described in the official description. It is important to accurately document the specific procedures performed to support the use of this code. Additionally, be aware of any specific billing guidelines or modifiers that may apply to this procedure.

8. Historical information

CPT 55801 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient undergoes a perineal prostatectomy, subtotal, along with control of postoperative bleeding and urethral calibration.
2. A provider performs a perineal prostatectomy, subtotal, with vasectomy and internal urethrotomy.
3. A patient undergoes a perineal prostatectomy, subtotal, along with meatotomy and urethral dilation.
4. A provider performs a perineal prostatectomy, subtotal, with control of postoperative bleeding and internal urethrotomy.
5. A patient undergoes a perineal prostatectomy, subtotal, along with vasectomy and meatotomy.
6. A provider performs a perineal prostatectomy, subtotal, with urethral calibration and internal urethrotomy.
7. A patient undergoes a perineal prostatectomy, subtotal, along with control of postoperative bleeding and vasectomy.
8. A provider performs a perineal prostatectomy, subtotal, with meatotomy and urethral dilation.
9. A patient undergoes a perineal prostatectomy, subtotal, along with vasectomy and urethral calibration.
10. A provider performs a perineal prostatectomy, subtotal, with control of postoperative bleeding and meatotomy.