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The procedure described by CPT® Code 55842 refers to a retropubic radical prostatectomy, which is a surgical intervention aimed at the removal of the prostate gland along with surrounding tissues. This procedure may be performed with or without nerve-sparing techniques, which are designed to preserve the nerves that control erectile function. The surgery involves an incision in the midline of the lower abdomen, allowing access to the prostate and surrounding structures. A key component of this procedure is the lymph node biopsy, which may involve a limited pelvic lymphadenectomy, where specific pelvic lymph nodes are examined for the presence of malignancy. The approach is meticulous, ensuring that critical anatomical structures, such as the genitofemoral nerve and psoas muscle, are preserved during the dissection. The procedure is comprehensive, addressing both the prostate and any potentially affected lymph nodes, thereby providing essential information regarding the extent of cancer spread and guiding further treatment decisions.
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The retropubic radical prostatectomy with lymph node biopsy, as described by CPT® Code 55842, is indicated for patients diagnosed with prostate cancer. The procedure is typically performed when there is a need to remove the prostate gland due to malignancy, particularly when there is a concern for the spread of cancer to nearby lymph nodes. The following conditions may warrant this surgical intervention:
The procedure for CPT® Code 55842 involves several critical steps to ensure the effective removal of the prostate and assessment of lymph nodes. The following procedural steps are performed:
Post-procedure care following a retropubic radical prostatectomy with lymph node biopsy includes monitoring for complications such as bleeding, infection, and urinary retention. Patients may require a catheter for urinary drainage for a period following surgery. Recovery typically involves pain management and gradual resumption of normal activities. Follow-up appointments are essential to assess healing and discuss pathology results from the lymph node biopsies, which will inform further treatment options if necessary. Patients are advised to adhere to postoperative instructions regarding activity restrictions and signs of complications to ensure optimal recovery.
| Short Descr | EXTENSIVE PROSTATE SURGERY | Medium Descr | PROSTECT RETROPUBIC RAD W/WO NRV SPAR W/LYMPH BX | Long Descr | Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 114 - Open prostatectomy |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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