Outpatient Facility Coding Alert

Know when you need modifiers 58 and 78.

Coding the first transurethral resection of prostate (TURP) procedure a patient undergoes is fairly 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]), says Melanie B. Scott, CPC, PCS, business office manager at Five Valleys Urology in Missoula, Mont.

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 52601 along with diagnosis code 600.01 (Hypertrophy [benign] of prostate with urinary obstruction and other lower urinary tract symptoms [LUTS]).

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,” Scott warns. 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.

Option 1: 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,” Scott confirms. “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.”

Employ Modifier 78 for Unplanned Repeat Procedures

Option 2: When your urologist performs a resection for residual tissue or regrowth any time after the original TURP, you should report 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

If the patient is still within the global period of the initial TURP procedure when your urologist performs the repeat resection, add modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 52630, according to Scott. If you are beyond the initial 90-day global, just report 52630.

Key: You need to thoroughly review your urologist’s notes, including the full patient history, to be sure you don’t report 52601 by mistake. Even if another urologist performed the original TURP years ago, you still have to report 52630 for the repeat procedure.

“Our physicians at Five Valleys Urology are very good about documenting in the office notes or the H&P as well as the op report that the patient previously had a TURP, so we just need to check in the records to see that we have to bill 52630,” Scott says. “If the patient himself was not sure we would check in the medical records from the referring physician to avoid improper billing and denial of our claims.”

Example: Your urologist is treating a patient who had prostatic surgery three years ago by another physician. The patient has had significant regrowth of prostatic tissue and is symptomatic. The urologist decides to perform a second TURP. Although the work involved for the repeat resection may be equivalent to an initial TURP, you should still report 52630, not 52601, because of the history of a prior TURP.