Laparoscopic simple prostatectomy code is coming

Jonathan Rubenstein, MD

When is there going to be a code for laparoscopic simple prostatectomy?

The answer is January 1, 2023. Each year, the American Medical Association (AMA) updates the Current Procedural Terminology (CPT) code set. A number of criteria need to be met for a procedure to get its own CPT code. There finally were enough data (and enough interest) for a CPT code to be created for laparoscopic simple subtotal prostatectomy. On January 1, the following CPT code will be active: 55867 (laparoscopy, surgical prostatectomy, simple subtotal [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy], includes robotic assistance, when performed).

Mark Painter

Prior to this, an unlisted CPT code was most appropriate to report this service. The AMA does believe that procedures are approach dependent, so if a procedure is performed by the laparoscopic approach and there is no specific laparoscopic code, an unlisted code should be reported. There had been insurances that accepted the open simple subtotal prostatectomy codes (CPT codes 55831 and 55821 for retropubic and suprapubic approaches, respectively) for reporting a laparoscopic simple prostatectomy procedure, which would be incorrect if following AMA/CPT rules but would be allowed if there was an agreement based upon the patient’s insurer. With the addition of this new CPT code, it will be even clearer that CPT codes 55831 and 55821 should be reported only for an open simple prostatectomy. If there is a payer that continues to request the open procedure CPT codes, we recommend you attempt to obtain this request in writing or, as a second choice, record the name and identification of the individual(s) who have provided this instruction for that payer.

All payers under the Health Insurance Portability and Accountability Act are required to adopt current CPT code sets. Beginning January 1, 2023, there will be only 1 laparoscopic code if the approach is laparoscopic, no matter what is done internally (such as an internal suprapubic or retropubic approach). It is important that coders and providers understand when to use CPT code 55867 and clearly document it to allow others to see this is used for a simple subtotal procedure and not a radical (for cancer) procedure that would be coded with CPT codes 55840, 55842, or 55845 for an open radical prostatectomy or 55866 for a laparoscopic radical prostatectomy.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.