2025 CPT code 55845
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Male Genital System Surgery Feed
Radical retropubic prostatectomy with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes.Nerve sparing may or may not be performed.
Modifiers may be applicable in certain scenarios, such as increased procedural services (22), multiple procedures (51), reduced services (52), or assistant surgeon (80).
Medical necessity is established by a diagnosis of prostate cancer and the clinical rationale for performing a radical prostatectomy with lymphadenectomy. The decision to include lymphadenectomy is based on factors like PSA level, Gleason score, and clinical stage.
The surgeon is responsible for the complete surgical procedure, including patient positioning, anesthesia, incision, lymphadenectomy, prostate removal, anastomosis of the bladder to the urethra, and closure of the incisions.The surgeon also decides whether nerve-sparing is appropriate.
In simple words: This surgery removes the prostate gland and nearby tissues, including lymph nodes in the pelvis. The surgeon may also try to preserve the nerves responsible for erectile function.
The surgeon performs a radical retropubic prostatectomy, removing the prostate gland and surrounding tissues. This includes a bilateral pelvic lymphadenectomy, excising lymph nodes from the external iliac, hypogastric, and obturator regions. The procedure may or may not involve nerve-sparing techniques.
Example 1: A 65-year-old male with localized prostate cancer and a high PSA level undergoes radical retropubic prostatectomy with bilateral pelvic lymphadenectomy (55845) to remove the cancerous prostate and assess lymph node involvement., A 70-year-old male with a high Gleason score indicating aggressive prostate cancer undergoes 55845.Due to his age and the aggressiveness of the cancer, nerve-sparing techniques are not attempted., A 55-year-old male diagnosed with early-stage prostate cancer opts for 55845 with nerve-sparing to maximize the chances of preserving erectile function.
Documentation should include operative report detailing the procedure, including the extent of lymphadenectomy, whether nerve-sparing was performed, and any complications. Pathology report confirming prostate cancer and lymph node involvement should also be included.
- Revenue Code: P1G - Major Procedure - Other
- Payment Status: Active
- Specialties:Urology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center