CPT code 55812 is for a perineal radical prostatectomy with limited pelvic lymph node biopsy, used to classify and document this medical procedure.
CPT code 55812 is used to describe a surgical procedure known as a perineal radical prostatectomy, which involves the removal of the prostate gland through an incision made in the perineum, the area between the scrotum and the anus. This procedure is typically performed to treat prostate cancer. In addition to the prostatectomy, this code also includes the performance of a limited pelvic lymphadenectomy, which involves the biopsy or removal of a small number of lymph nodes in the pelvic region to check for the spread of cancer. This comprehensive approach helps in both treating the cancer and assessing its potential spread.
For CPT code 55812, which involves a prostatectomy with lymph node biopsy(s), the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: This modifier is used when the work required to perform the procedure is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier indicates that multiple procedures were carried out.
3. Modifier 59 - Distinct Procedural Service: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.
4. Modifier 62 - Two Surgeons: When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report their distinct operative work by adding this modifier.
5. Modifier 66 - Surgical Team: This modifier is used when a complex procedure requires the services of several physicians, often of different specialties, working together as a team.
6. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required during the procedure. The assistant surgeon provides additional support to the primary surgeon.
7. Modifier 81 - Minimum Assistant Surgeon: This is used when an assistant surgeon is required on a limited basis during the procedure.
8. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is required, and a qualified resident surgeon is not available.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. Proper documentation is essential when using these modifiers to justify their application.
The CPT code 55812 is reimbursed by Medicare, but the reimbursement is subject to several factors. The Medicare Physician Fee Schedule (MPFS) is a critical resource that determines the reimbursement rates for services covered under Medicare Part B, including surgical procedures like those associated with CPT code 55812. The MPFS provides a comprehensive list of fees that Medicare will pay for each service, which is updated annually to reflect changes in practice costs, geographic adjustments, and policy updates.
Additionally, Medicare Administrative Contractors (MACs) play a significant role in the reimbursement process. MACs are responsible for processing Medicare claims and have the authority to make local coverage determinations (LCDs) that can affect whether a specific service is reimbursed in their jurisdiction. Therefore, while CPT code 55812 is generally reimbursed by Medicare, healthcare providers should verify the specific reimbursement details with their local MAC to ensure compliance with any regional policies or requirements that may impact payment.
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