CPT code 55815 is for a radical prostatectomy via the perineal approach, including removal of pelvic lymph nodes like external iliac and obturator nodes.
CPT code 55815 is used to describe a surgical procedure known as a perineal radical prostatectomy with bilateral pelvic lymphadenectomy. This procedure involves the removal of the prostate gland through an incision made in the perineum, which is the area between the scrotum and the anus. In addition to the prostatectomy, this code indicates that the surgeon also performs a bilateral pelvic lymphadenectomy. This means that lymph nodes from both sides of the pelvis, specifically the external iliac, hypogastric, and obturator nodes, are removed. This comprehensive procedure is typically performed to treat prostate cancer and allows for the examination of lymph nodes to determine if cancer has spread beyond the prostate.
For CPT code 55815, the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 (Increased Procedural Services): Used when the work required to perform the procedure is substantially greater than typically required. This could be due to complications or other factors that increase the complexity of the surgery.
2. Modifier 51 (Multiple Procedures): Applicable if multiple procedures are performed during the same surgical session. This modifier indicates that the prostatectomy was one of several procedures.
3. Modifier 59 (Distinct Procedural Service): Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This might be necessary if additional, unrelated procedures are performed.
4. Modifier 62 (Two Surgeons): If two surgeons are required to perform distinct parts of the procedure, this modifier is used to indicate the collaborative effort.
5. Modifier 66 (Surgical Team): Applicable when a highly complex procedure requires the skills of a surgical team, indicating that multiple professionals were involved.
6. Modifier 80 (Assistant Surgeon): Used when an assistant surgeon is necessary to aid in the procedure.
7. Modifier 81 (Minimum Assistant Surgeon): Indicates that an assistant surgeon was required for a minimal portion of the procedure.
8. Modifier 82 (Assistant Surgeon when Qualified Resident Surgeon Not Available): Used when an assistant surgeon is necessary, and a qualified resident surgeon is not available.
9. Modifier 99 (Multiple Modifiers): If more than four modifiers are necessary to describe the service, this modifier indicates that multiple modifiers are being used.
These modifiers should be applied based on the specific details and circumstances of the surgical procedure to ensure accurate billing and reimbursement.
CPT code 55815 is reimbursed by Medicare, but the reimbursement is subject to several factors. The Medicare Physician Fee Schedule (MPFS) determines the payment rates for services covered under Medicare Part B, including surgical procedures like those associated with CPT code 55815. The reimbursement amount can vary based on geographic location and other factors, as determined by the Medicare Administrative Contractor (MAC) responsible for processing claims in a specific region. It is important for healthcare providers to verify the specific reimbursement details with their local MAC and ensure that all necessary documentation and coding guidelines are followed to facilitate proper reimbursement.
Discover the power of MD Clarity's RevFind software to ensure you're receiving the full reimbursement you deserve. With the ability to read your contracts and detect underpayments down to the CPT code level, including specific codes like 55815, RevFind provides unparalleled accuracy and insight. Schedule a demo today to see how RevFind can help you identify discrepancies by individual payer and optimize your revenue cycle management.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
