Did you know that by age 60, 50% of men experience an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Besides, by age 85, the proportion reaches 90%.
While traditional treatment options are available to cure the condition, they may not always improve it. Thus, surgical intervention becomes necessary.
This guide is dedicated to discussing the surgical procedure covered under CPT code 52601. From clinical scenarios to applicable modifiers and reimbursement guidelines, we will cover everything you need to know to ensure timely reimbursement for this surgery. So, continue reading!
CPT Code 52601 – Description
CPT code 52601 covers transurethral resection of the prostate (TURP). The urologist inserts a resectoscope via the urethra to remove a portion of the prostate.
The reimbursement for several other urological surgery services is included in this code, such as urethral dilation, meatotomy, and cystoscopy.
Note: It is a major surgery with a 90-day global period. This means that routine office visits related to recovery during this timeframe cannot be billed separately.
Appropriate Use Cases for CPT Code 52601
Let’s review a few real-world clinical scenarios where CPT 52601 applies:
Severe Benign Prostatic Hyperplasia (BPH)
Picture a 66-year-old male patient who visits the urology clinic with complaints of worsening lower urinary tract symptoms (LUTS). These include a weak stream, nocturia, and a high post-void residual (PVR).
He has already undergone maximum medical therapy with finasteride and tamsulosin, but in vain. As a result, the urologist performs a complete TURP covered under CPT code 52601. He inserts the resectoscope and conducts an initial cystoscopy to remove the obstructive prostatic tissue using an electrical loop.
Acute Urinary Retention (AUR)
Suppose a 71-year-old male patient is admitted to the surgical facility for emergency treatment after experiencing a total blockage of urine flow.
The urologist initially tried to pass a standard Foley catheter. However, it failed due to an enlarged median lobe of the prostate. Therefore, the patient is scheduled for a complete TURP following emergency decompression with a Coude catheter.
Here, the urologist should report CPT code 52601 to bill for the complete TURP, including meatotomy.
Recurrent Urinary Tract Infections (UTIs)
Imagine an 80-year-old male patient with a history of three bouts of urosepsis in the last 12 months.
The urologist orders an ultrasound and urodynamic testing. The findings revealed that the prostatic obstruction is causing significant urinary stasis, leading to recurrent infections.
Thus, the urologist decides to perform a complete TURP (CPT code 52601) to eliminate the source of stasis. Additionally, at the end of the surgery, the provider utilizes extensive electrocautery to ensure hemostasis.
Modifiers to Append with CPT Code 52601
Discussed below are some of the modifiers that apply to CPT 52601:
Modifier 51
What happens when the healthcare practitioner performs a complete TURP in the same surgical session as another procedure? You report CPT code 52601 with modifier 51 to indicate multiple procedures.
Modifier 58
You should append modifier 58 when the urologist performs part 2 of the TURP surgery during the recovery period of part 1. Simply put, this modifier applies when the second surgery was planned or anticipated during the first surgery.
Let’s consider an example for better understanding!
A patient came to the hospital for a scheduled TURP surgery (CPT code 52601). While performing it, the urologist realizes that continuing the surgery would risk a dangerous fluid imbalance since the patient has an extremely large prostate.
As a result, the surgeon removes the tissue as safely as possible. He then explicitly states in the operating notes that the surgery was stopped due to excessive gland size to ensure patient safety. Moreover, the second-stage TURP is planned after four weeks.
When the patient returns to the operating room, the urologist removes the remaining prostate tissue.
Thus, you must report the second TURP with modifier 58.
Reimbursement Guidelines for CPT Code 52601
The following are the essential reimbursement requirements for CPT 52601:
Understand the ‘Once-in-a-Lifetime’ Rule
CPT code 52601 is a one-in-a-lifetime procedure. That is, you can only bill it once for each patient.
So, what happens when the patient develops a condition that requires conducting the TURP again later in life? You should bill the service using CPT 52630.
Special Scenario: If the prostate tissue is too large and you need to perform a staged TURP during the 90-day global period of the initial service, you can report 52601 again, but not without modifier 58.
Justify the Medical Necessity
Your documentation must demonstrate the medical necessity for performing a complete TURP (CPT code 52601) to ensure timely processing of the claim. Thus, include the following:
- Significant symptoms of urinary obstruction (high AUA Symptom Score).
- Failure of pharmacological treatment (e.g., alpha-blockers like Tamsulosin).
- Documented residual urine or flow rate studies.
Fulfill the Documentation Requirements
Detailed operative notes are needed as evidence to prove that all elements covered in the CPT code 52601 were performed by the urologist. Here’s what it should include:
- Explicitly mention that the surgeon performed transurethrally via cystourethroscopy.
- Mention which instruments were utilized, i.e., the resectoscope and the use of an electrosurgical unit (monopolar or bipolar).
- Specify the anatomy, i.e., the resection of the median and/or lateral lobes of the prostate.
- Document how the provider controlled the postoperative bleeding (hemostasis).
- Mention that the performance of vasectomy or meatotomy was performed to offer a complete clinical picture.
Summary
With that said, it is time to say adieu. But, before concluding, let’s summarize the guide.
CPT code 52601 covers the removal of prostate tissue (TURP). You can only bill it once in a lifetime for each patient. That is, if the patient requires the TURP procedure again later in their life, you should bill it using a different procedural code, i.e., CPT 52630.
Hopefully, this guide will help you ensure clean claim submission for this integral surgical intervention. However, if you still struggle, feel free to outsource urology billing services to professionals, like NeuraBill.
