CPT code 55821 is for a prostatectomy procedure involving partial removal of the prostate through the abdomen, possibly in one or two stages.
CPT code 55821 is used to describe a surgical procedure known as a suprapubic subtotal prostatectomy. This procedure involves the partial removal of the prostate gland through an incision made in the lower abdomen, above the pubic bone. The code also encompasses additional related procedures that may be performed during the surgery, such as controlling postoperative bleeding, performing a vasectomy, conducting a meatotomy (an incision to widen the urethral opening), calibrating or dilating the urethra, and performing an internal urethrotomy (an incision within the urethra to relieve a stricture). The procedure can be completed in one or two stages, depending on the specific clinical circumstances and the surgeon's approach.
For CPT code 55821, the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 - Increased Procedural Services: Use this modifier if the procedure required significantly more work than typically required. This could be due to complications or unexpected findings during surgery.
2. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier indicates that more than one procedure was performed.
3. Modifier 52 - Reduced Services: Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
4. Modifier 53 - Discontinued Procedure: Use this modifier if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
5. 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.
6. Modifier 62 - Two Surgeons: If two surgeons are required to perform the procedure, this modifier indicates that each surgeon performed a distinct part of the procedure.
7. Modifier 66 - Surgical Team: Use this modifier when a team of surgeons is required to perform the procedure due to its complexity.
8. Modifier 76 - Repeat Procedure or Service by Same Physician: If the same physician repeats the procedure on the same day, this modifier is applicable.
9. Modifier 77 - Repeat Procedure by Another Physician: If a different physician repeats the procedure on the same day, this modifier should be used.
10. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This modifier is used if the patient needs to return to the operating room for a related procedure during the postoperative period.
11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if an unrelated procedure is performed by the same physician during the postoperative period.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. Always refer to the latest coding guidelines and payer-specific policies when applying modifiers.
The CPT code 55821 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 55821. The MPFS provides a standardized payment structure, but actual reimbursement can vary based on geographic location and other factors.
Additionally, Medicare Administrative Contractors (MACs) play a crucial 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 and how a specific CPT code is reimbursed. Therefore, while CPT code 55821 is generally reimbursable under Medicare, healthcare providers should verify specific coverage and reimbursement details with their respective MAC to ensure compliance with any local policies or requirements.
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 55821, RevFind provides unparalleled accuracy in identifying discrepancies by individual payer. Schedule a demo today to see how RevFind can enhance your revenue cycle management and safeguard your practice's financial health.
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
