You have two choices when coding for robotic radical prostatectomy

Q:

How do I code a radical pros-tatectomy performed with the da Vinci robot? I understand reimbursement will not differ, but should it be billed differently?

A:

Currently there are several code choices when using the da Vinci system (Intuitive Surgical, Sunnyvale, CA) to perform a robotic radical prostatectomy. The two main CPT code choices are 55866 (laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing); and 55899 (unlisted procedure, male genital system). 

Neither of the codes listed above are incorrect at this time, and there is yet another option for reporting the service by adding the –22 modifier to the 55866. Depending on the payer rules and payment determinations, coding may be different within the same practice.

There are pros and cons to using each code. The robotic procedure is performed through the laparoscope; therefore, 55866 is an accurate reporting of the service. 

However, many urologists do not think it accurately reflects the added cost of the equipment, complexity of the surgery, or the additional time spent. The 55866 will be paid in a timely fashion by most payers, but will limit payment to the Medicare allowable, or to some multiple of that amount, according to your contracts. 

Using the unlisted code will always delay payment and at times it will require you to file an appeal, but it has allowed urologists to negotiate a higher payment with some payers and/or the patient. 

Q:

I implant the sural nerve taken from the leg into the area of the prostate when the prostate has been transected. I cannot find a code that seems appropriate for this procedure in the CPT book. What code would you suggest?

 

A:

Unfortunately there is no good code for the service you have described. We will assume that the service is provided at the same session in which the prostate has been removed. If this is the case, we recommend adding the unlisted “nervous system” code 64999 or adding –22 to the prostatectomy code. 

Q:

Is there a code for release of a buried penis? The patient is obese and the penis was beneath the fat pad. I have searched for a code but can’t seem to find one. The hospital is also stuck on this one.

A:

There is no specific code. It is impossible to provide an answer for this question without further information, such as an operative note. Considering the possibilities of exploration, skin excision, and fat removal, the coding combinations are too numerous to cover. 

We suggest that you abstract each component of the surgery from the operative note. Determine the appropriate code for each component, such as a 10000 series code for skin flaps, resection of fat, etc. If appropriate, you could use code 55899 (unlisted procedure, male genital system) to report the entire surgery or a portion of the surgery.

Q:

Can I receive payment for providing penile rehabilitation services after a radical prostatectomy? If so, how should I bill for the services provided?

A:

Treating a patient for erectile dysfunction during the postoperative period is an area of conflicting rules. On the one hand, the erectile dysfunction is definitely a result of the surgery, and, according to the global rules, it would not be billable. However, there is another set of rules that states that you should be paid for “therapy following a surgical procedure” (one of the definitions of the –58 modifier in the 2008 CPT book). Medicare agrees that treatment of an underlying disease process should be reimbursed. This certainly should be considered treatment of an underlying or resulting disease. Therefore, you are fully justified in charging for those services using the –58 modifiers attached to the service provided. 

For instance, if you were seeing a patient for routine post-op follow-up or for a complication of the surgery, you would not charge for the E&M service. However, if you are injecting the penis as a part of penile rehab on the same visit, then you charge for that procedure using the –58 modifier. On the other hand, if you were to see the patient specifically for a discussion of erectile dysfunction and the potential treatment, then you could charge the E&M service as well, using the –58 modifier based on the 2008 definition of the modifier “–58.” However, Medicare guidelines indicate that use of modifier –58 is not indicated with E&M services. Further definition of modifier –24 in the Medicare manual would indicate that this modifier would not be appropriate either; therefore, payment for the E&M service by Medicare may not be allowed. 

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook

 

Mark Painter is CEO of PRS Urology SC in Denver. 

 

Disclaimer:

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.