Is the once-in-a-lifetime procedure rule for CPT code 52601 still valid? Let’s update your knowledge! Benign prostatic hyperplasia (BPH) is a common condition among aging men, affecting 5 to 6% of men between ages 40 to 64 and 29 to 33% of those older than 65.
While transurethral resection of the prostate (TURP) is the most common treatment for this disease, there is one problem: many healthcare providers struggle to bill for this procedure due to unclear coding guidelines. How often do you face the same challenge? Let’s explore the specifics of CPT code 52601, a popular code for reporting the prostatic surgical procedure –TURP.
CPT Code 52601 – Description
As mentioned in the intro, CPT code 52601 refers to the transurethral resection of the prostate (TURP). This is the most popular surgical treatment for enlarged prostate or benign prostatic hyperplasia (BPH), to be more specific.
But what exactly is a BPH? It is a common non-cancerous condition among aging men that causes the prostate, a gland resting below the bladder, to increase in size. This disease causes blockage in the patient’s urethra, making it difficult for him to empty his bladder.
CPT code 52601 covers a complete transurethral resection of the prostate involving several other urological procedures, including:
- Cystoscopy (a service for examining the lining of the patient’s bladder and urethra)
- Meatotomy (a surgery for widening the opening of the ureter)
- Urethral dilation (a procedure to stretch the sides of the urethra)
So, what happens during TURP? A surgeon removes obstructing prostatic tissue by inserting a resectoscope (a thin, tube-like instrument) through the patient’s urethra. The other services mentioned above facilitate this minimally invasive surgery.
Scenarios Where CPT Code 52601 is Applicable
Let’s consider a few scenarios to understand how you can bill for CPT code 52601.
Severe Urinary Retention
Let’s start with a common case! Suppose a 76-year-old man arrives at an emergency department due to acute urinary retention, a condition in which he is completely unable to empty his bladder. The urologist performs a urinalysis and imaging tests to determine the cause of the patient’s condition.
The results reveal that an enlarged prostate is causing the obstruction. The healthcare provider, therefore, performs a complete TURP to remove the obstructing tissue. He then reviews the patient’s medical records to check if this procedure has been performed before. After finding no evidence, the provider reports the TURP with CPT code 52601.
Repeated Urinary Tract Infections (UTIs) Due to BPH
Did you know that about 33.33% of patients with benign prostatic hyperplasia (BPH) develop urinary tract infection (UTI)? Let’s consider an example!
Assume a 64-year-old man frequently suffers from UTIs due to an enlarged prostate. After undergoing several courses of antibiotics without relief, he visits a urology clinic for further evaluation. The doctor assesses the patient’s condition and decides to perform a transurethral resection of the prostate to remove the obstruction.
Since this is the patient’s first TURP, the provider bills the procedure with CPT code 52601.
Risk of Developing Bladder Stones Due to BPH
Suppose a 51-year-old man experiences severe abdominal pain while urinating and has difficulty completely emptying his bladder. The doctor suspects bladder stones and performs imaging tests to confirm the diagnosis. While the results reveal that a significantly enlarged prostate is the reason behind the pain, the patient is at high risk of developing bladder stones.
Therefore, the surgeon performs TURP to remove the excess tissue, improving bladder drainage and preventing stone formation. The provider then reports the procedure using CPT code 52601, indicating that this is the patient’s first TURP.
Applicable Modifiers for CPT Code 52601
Code 52601 was previously considered a once-in-a-lifetime procedure. However, you can now bill it again for a staged, related TURP with the following modifier.
Modifier 58
You can use CPT code 52601 with modifier 58 to bill for a second TURP if it was staged during the post-operative period of the initial procedure. For example, if a urologist decides on a follow-up TURP during the preoperative care of the first procedure, he should append modifier 58 to the second procedure’s code (CPT code 52601-58).
CPT Code 52601 vs. 52630
There isn’t much difference between these two codes. Both CPT codes 52601 and 52630 refer to transurethral resection of the prostate (TURP) — a procedure where a specialized surgeon removes excess prostate tissue to improve urine flow. However, these codes are used in different scenarios. Here is how they differ:
Key Difference
CPT code 52601 reports the initial TURP. It means billing specialists only use this code when a urologist performs TURP for the first time to remove excess prostate tissue in a patient with benign prostatic hyperplasia (BPH). Simply put, you should only use CPT 52601 if the patient has never undergone this procedure previously.
On the other hand, CPT code 52630 indicates a repeat TURP. In simple terms, billing teams apply this code when a surgeon removes residual prostate tissue after a previous TURP or regrowth. In short, you should report any TURP performed after the initial one with this code.
CPT Code 52601 – Billing & Reimbursement Guidelines
You can follow our documentation and billing tips for CPT code 52601 to file accurate claims:
Verify Medical Necessity for TURP
As always, the first step before performing or billing any procedure is to verify its medical necessity. This step will help you avoid future complications. So, how can you do that? By making sure that the patient’s diagnosis justifies the procedure!
Identify the correct symptoms, such as a weak urine stream or difficulty starting or stopping urination, review the test results, and use the appropriate ICD-10 codes to support your decision to perform TURP.
Familiarize Yourself with CPT Code 52601’s Requirements
Remember, CPT code 52601 is a comprehensive code with a 90-day global period. It simply means it covers all relevant pre-, intra-, and post-operative procedures, such as vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy.
Therefore, you should not separately bill ancillary procedures included in a complete TURP.
Apply Modifier 58 to Report a Related, Staged TURP
If a follow-up TURP is required during the global period, use CPT code 52601 with Modifier 58 to report this staged surgery.
Submit Proper Documentation
Another advice is to record everything you did during the procedure verification process. This includes documenting the patient’s symptoms, current condition, test results, and correct diagnostic codes in the medical records.
Additionally, maintain a detailed operative report, including details of the TURP procedure, such as the amount of tissue resected, ancillary procedures performed (e.g., cystourethroscopy or urethral dilation), and any complications. Do not forget to include post-operative notes.
Check Payer Policies Before Submission
Public and private insurers may have different reimbursement policies for CPT code 52601. Some may even require prior authorization. Therefore, verify their requirements before filing any claim to avoid common mistakes such as missing or incomplete documentation, global period violations, or incorrect coding.
Summary
To summarize, urinary problems like BPH are quite prevalent in aging men. Therefore, transurethral electrosurgical resection of the prostate (TURP) is a frequently performed surgical procedure by urologists. CPT code 52601 is an appropriate code to report the first TURP procedure.
In simple words, billing specialists use this code when a surgeon removes as much prostate tissue as reasonable and necessary to improve the patient’s urine flow. There is no specific maximum or minimum amount of tissue to be resected. This code covers a complete TURP involving several urology procedures. We have simplified CPT code 52601 so you can use it accurately. But if you prefer professional expertise, you can always opt for one of the reliable urology billing services.
Frequently Asked Questions
