Coding the first transurethral resection of prostate (TURP) procedure a patient undergoes, is straightforward, but when the patient needs a follow-up or repeat procedure, coding for the second procedure can get complicated. You need to scour your urologist’s documentation to capture all the details, including critical history notes, before choosing your codes.
Follow this expert advice to properly code second — and subsequent —TURP procedures.
Start with 52601 for First Procedure
If your urologist performs a TURP for a patient who has never had a TURP in the past, report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included.
Example: Your urologist sees a patient with frequent urination and nocturia and makes a diagnosis of benign prostatic hyperplasia (BPH), also known as an enlarged prostate gland. Because the patient’s symptoms are severe, your urologist decides to perform a TURP. You should report CPT 52601.
Watch out: The TURP procedure and the definition of 52601, includes several other urological services. “Remember that a vasectomy, meatotomy, cystourethroscopy, urethral calibration, urethral dilation, and internal urethrotomy are included in procedure code 52601 as well as 52630 and cannot be billed separately. Because these procedures are intrinsically part of a TURP procedure, you should not report them separately and, therefore, you should report only 52601.
Support Planned Follow-Up Procedure With 58
There may be times when your urologist needs to perform a second TURP procedure. How you code for that follow-up procedure depends on planning and the timing of the second surgery.
If your urologist preoperatively considers staging a TURP or when performing a TURP he determines that the procedure cannot be completed at one sitting because of the excessive size of the prostate and operative time restraints, he may opt to perform a second TURP within the 90-day global period of the first surgery. In these cases the physician should indicate in his medical record or operative report that the patient may require a second staged TURP. This documentation would then support a future claim for a subsequent staged TURP procedure.
Report 52601 for the first procedure, as explained above. Then, for the second staged procedure, report 52601 again. However, if the second surgery is planned as a staged procedure and occurs during the global of the first procedure, you should append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the second procedure.
“Per CPT®, the first stage is coded as 52601. The second stage, when planned and noted in the op report of the first stage is coded 52601-58.
Don’t focus on past advice: Several years ago, urology coders followed the rule that 52601 was a “once in a lifetime procedure,” meaning you could only report a TURP once in a patient’s life. This changed on Jan. 1, 2009 when CPT® updated the coding for a staged TURP. The clinical scenario described above is an exception to the old rule.
Official guidance: CPT® states the following: “For first stage transurethral partial resection of prostate, use 52601. For second stage partial resection of prostate, use 52601 with modifier 58.”
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