How To Use CPT Code 52601

CPT 52601 refers to the transurethral electrosurgical resection of the prostate, including control of postoperative bleeding and other related procedures. This article will cover the description, procedure, qualifying circumstances, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 52601.

1. What is CPT 52601?

CPT 52601 is a medical procedure code used to describe the transurethral electrosurgical resection of the prostate (TURP), which involves the removal of a portion of the prostate gland through the urethra. This code also includes control of postoperative bleeding and other related procedures such as vasectomy, meatotomy, cystourethroscopy, urethral calibration, and/or dilation, and internal urethrotomy.

2. 52601 CPT code description

The official description of CPT code 52601 is: “Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)”.

3. Procedure

1. Administration of anesthesia and positioning of the patient in a dorsal lithotomy position.
2. Prepping and draping the patient in a sterile fashion.
3. Insertion of a cystourethroscope to examine the bladder.
4. Enlargement of the urethral opening (meatus) by incision and dilation of the urethra if needed.
5. Resection of the vas deferens if necessary.
6. Resection of the prostate gland using a resectoscope loop, starting at the bladder neck and moving down to the circular capsular fibers.
7. Resection of the left and right lateral lobes of the prostate, obtaining hemostasis along the way.
8. Trimming of the apex and obtaining hemostasis.
9. Removal of instruments and completion of the procedure.

4. Qualifying circumstances

Patients eligible to receive CPT code 52601 services are those diagnosed with benign prostatic hyperplasia (BPH) or other prostate-related conditions that require the removal of a portion of the prostate gland. The patient must not have undergone a TURP procedure previously, as CPT 52601 represents a once-in-a-lifetime procedure.

5. When to use CPT code 52601

It is appropriate to bill the 52601 CPT code when a patient undergoes a complete transurethral electrosurgical resection of the prostate, including control of postoperative bleeding and other related procedures. This code should not be used for partial resections or for patients who have previously undergone a TURP procedure.

6. Documentation requirements

Documentation supporting a claim for CPT 52601 should include the patient’s medical history, diagnosis, and indication for the procedure. Additionally, a detailed operative report describing the steps of the procedure, any complications, and postoperative care should be included. The documentation must clearly demonstrate the medical necessity of the TURP procedure and the inclusion of related procedures.

7. Billing guidelines

When billing for CPT code 52601, it is important to remember that this code includes several other urological services, such as meatotomy and urethral dilation. These procedures should not be reported separately. Additionally, the choice of TURP code should not be based on the technique used or the amount of prostatic tissue removed. For first stage transurethral partial resection of the prostate, see CPT 52601. For a second stage partial resection of the prostate, use CPT 52601 with appended modifier 58.

8. Historical information

CPT 52601 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 52601

Five similar codes to CPT 52601 include:

• CPT 0421T: Transurethral waterjet ablation of the prostate.
• CPT 55801: Radical perineal prostatectomy.
• CPT 55810: Radical retropubic prostatectomy.
• CPT 55812: Radical retropubic prostatectomy with bilateral pelvic lymphadenectomy.
• CPT 55840: Prostatectomy, retropubic subtotal, including nerve sparing.

These codes differ from CPT 52601 in the approach, technique, or extent of the prostate removal.

10. Examples

Here are 10 detailed examples of CPT code 52601 procedures:

1. A 65-year-old male with BPH undergoes a complete TURP procedure with control of postoperative bleeding and urethral dilation.
2. A patient with recurrent urinary tract infections due to an enlarged prostate undergoes a TURP procedure, including cystourethroscopy and internal urethrotomy.
3. A 70-year-old male with urinary retention caused by prostate enlargement undergoes a TURP procedure with vasectomy and meatotomy.
4. A patient with a history of hematuria and an enlarged prostate undergoes a TURP procedure with control of postoperative bleeding and urethral calibration.
5. A 75-year-old male with lower urinary tract symptoms due to BPH undergoes a TURP procedure, including resection of the left and right lateral lobes of the prostate.
6. A patient with a large median lobe of the prostate causing bladder outlet obstruction undergoes a TURP procedure with trimming of the apex and obtaining hemostasis.
7. A 68-year-old male with a history of urinary incontinence and an enlarged prostate undergoes a TURP procedure with urethral dilation and internal urethrotomy.
8. A patient with a history of urinary frequency and urgency due to prostate enlargement undergoes a TURP procedure, including resection of the prostate gland using a resectoscope loop.
9. A 72-year-old male with nocturia and an enlarged prostate undergoes a TURP procedure with control of postoperative bleeding and cystourethroscopy.
10. A patient with a history of bladder stones and an enlarged prostate undergoes a TURP procedure, including resection of the vas deferens and meatotomy.