Urology Coding Alert

Question: One of our patients was scheduled for an open radical prostatectomy because of prostate cancer. The surgeon completed a laparotomy. The prostate was attached to the rectum and inseparable from it. The patient had a right inguinal hernia, which the surgeon repaired. After making that repair, the operation was aborted due to the surgeon’s inability to separate the prostate from the rectum.

I see three possible code options for the encounter:

1. Radical prostatectomy with modifier 52
2. Radical prostatectomy with modifier 53
3. Exploratory laparotomy.

How do you think I should code this case?

Pennsylvania Subscriber

Answer: You best option probably is to submit CPT^® code 55840 (Prostatectomy, retropubic radical, with or without nerve sparing) as it appears that the surgeon did perform part of the procedure before terminating the surgery due to possible extension of the tumor into the rectum (which could be classified as extenuating circumstances). Add modifier 53 (Discontinued procedure) to indicate the termination of the surgical procedure.

However, the surgeon did complete a procedure (the inguinal hernia repair). Therefore, also code 49505 (Repair initial inguinal hernia, age 5 years or older, reducible).

If you are billing a commercial insurance, include a copy of the operative note. For a Medicare claim, make a note of “Additional information available upon request” in Box 19 and send the operative note when Medicare requests it.