2025 CPT code 55821

Suprapubic subtotal prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), one or two stages.

Follow current CPT coding guidelines for surgical procedures. Ensure proper documentation supporting the medical necessity of the procedure and the specific components performed.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 52 for reduced services, 22 for increased procedural services, 78/79 for unplanned return to OR).Proper modifier selection requires thorough understanding of the procedure performed and supporting documentation.

Medical necessity for a suprapubic subtotal prostatectomy is established by significant urinary obstruction symptoms (e.g., urinary retention, frequent urination, nocturia) unresponsive to conservative management, or by the presence of prostate cancer confined to the gland.The procedure should be medically necessary for the treatment of the patient's specific condition.

The urologist is responsible for performing the surgery, including prepping the patient, making the incision, dissecting to reach the prostate, excising the prostate and vas deferens, managing bleeding, calibrating/dilating/incising the urethra as needed, placing drainage catheters, irrigating the area, closing the incision, and monitoring postoperative recovery.

IMPORTANT For transurethral removal of the prostate, see codes 52601-52640. For transurethral destruction of the prostate, see codes 53850-53852.For limited pelvic lymphadenectomy for staging (separate procedure), use code 38562. For independent node dissection, see codes 38770-38780.

In simple words: The surgeon removes part of the prostate gland through a cut above the pubic bone. This may also involve cutting and widening the urinary tube, and measures to stop bleeding.Sometimes, this surgery is done in two separate operations.

This procedure involves the surgical removal of a portion of the prostate gland through a suprapubic incision (above the pubic bone).The procedure includes managing postoperative bleeding, vasectomy (excision of the vas deferens), meatotomy (incision of the urinary meatus), urethral calibration/dilation, and internal urethrotomy (incision of the urethra). It can be performed in one or two stages.

Example 1: A 65-year-old male presents with symptoms of benign prostatic hyperplasia (BPH) causing significant urinary obstruction. A suprapubic subtotal prostatectomy is performed to relieve the obstruction., A 70-year-old male is diagnosed with prostate cancer confined to the prostate gland. A suprapubic subtotal prostatectomy is performed as the primary treatment., A 72-year-old male has a large prostate causing urinary retention and recurrent bleeding. A two-stage suprapubic subtotal prostatectomy is planned to safely remove the enlarged tissue and control bleeding.

Preoperative assessment including history, physical exam, prostate-specific antigen (PSA) levels, urinalysis, and imaging studies (e.g., transrectal ultrasound). Intraoperative findings, including the extent of resection, tissue sent for pathology. Postoperative course, including drain output, catheterization details, and management of complications. Pathology report with diagnosis and staging.

** This code encompasses a range of procedures and requires precise documentation to ensure accurate billing.Specific details of tissue removed, complications encountered, and postoperative management should be clearly documented in the medical record.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • Payment Status: Active
  • Modifier TC rule: No TC modifier (Technical Component) applies to this code as it represents the entire surgical procedure.
  • Specialties:Urology
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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