55866

🩺 CPT Code 55866 - Laparoscopy, Surgical Prostatectomy, Radical, Retropubic, Including Nerve Sparing; Includes Robotic Assistance When Performed

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📋 Code Description

Full Official Description: Laparoscopy, surgical prostatectomy, radical, retropubic, including nerve sparing, includes robotic assistance when performed

CPT 55866 describes a laparoscopic radical prostatectomy (LRP) performed via a retropubic approach, with or without nerve-sparing technique, and inclusive of robotic-assisted technology when utilized. This is the correct CPT code for the widely performed robotic-assisted laparoscopic prostatectomy (RALP) — most commonly performed using the da Vinci Surgical System — and encompasses the entire surgical procedure including all components of the radical prostatectomy regardless of whether nerve sparing is performed on one or both sides.

The procedure involves:

• Laparoscopic or robotic port placement (typically 5-6 ports for robotic approach)
• Development of the space of Retzius (retropubic space) or alternatively a transperitoneal approach to the prostate
• Bladder neck dissection and separation from the prostate base
• Seminal vesicle and vas deferens dissection and excision
• Nerve-sparing dissection along the neurovascular bundles (NVBs) when indicated and oncologically appropriate — unilateral or bilateral
• Apical dissection and division of the urethra
• Complete excision of the prostate gland with attached seminal vesicles
• Vesicourethral anastomosis (bladder neck to urethral stump reconstruction)
• Specimen extraction via an extended port site or Pfannenstiel incision
• Pelvic drain placement when indicated

⚠️ Critical Coding Point: 55866 includes robotic assistance within the code descriptor. There is no separate CPT code for robotic assistance (e.g., S2900 is a HCPCS code used by some payers and facilities but is not universally accepted and is generally not separately reimbursed by Medicare). The robotic platform is bundled into 55866 by AMA definition.

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💰 Work RVUs & Payment

Component	Value
wRVU (Facility)	34.25
wRVU (Non-Facility)	34.25
Global Period	090 (ninety days)
Assistant Payable	✅ Yes (indicator: 1)
Co-Surgery	✅ Yes (indicator: 1)
Team Surgery	❌ No (indicator: 0)
Bilateral Surgery	N/A
Multiple Procedure Indicator	2 (standard reduction applies)
Endoscopic Base Code	N/A
Robotic Platform	Included — do not bill separately

90-Day Global Period: All related services — including standard postoperative visits, catheter management, and routine complications — are bundled into the global surgical package for 90 days post-operatively. Separately billable services within the global include unrelated conditions, return to the OR, and staged procedures.

Assistant at Surgery: 55866 carries an assistant surgeon indicator of 1, meaning Medicare and most commercial payers will reimburse an assistant surgeon at typically 16% of the primary surgeon’s allowable when billed with modifier -80, -81, or -AS (for a PA/NP first assist). Robotic console-side assistance is common and should be clearly documented.

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✅ What’s Included (Bundled into 55866)

The following are not separately reportable when performed as part of the same operative session as 55866:

• All laparoscopic port placements and trocar insertions
• Robotic system docking and undocking (da Vinci or equivalent)
• Bladder neck dissection
• Seminal vesicle dissection and removal (bilateral)
• Vas deferens ligation and excision (bilateral)
• Nerve-sparing dissection — unilateral or bilateral (the descriptor states “including nerve sparing”)
• Urethral dissection and division at the apex
• Vesicourethral anastomosis (posterior reconstruction of Rocco stitch and anastomosis)
• Pelvic drain placement (when performed as part of standard closure)
• Foley catheter placement
• Local/regional anesthesia administration by the surgeon (unusual; typically anesthesia bills separately)
• Standard intraoperative blood loss management
• Specimen extraction

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🚫 Excludes / Separately Reportable

Service	Separately Reportable Code	Notes
Pelvic lymph node dissection (PLND)	38571, 38572	See section below — critical add-on distinction
Limited pelvic lymph node biopsy (sentinel or limited)	38562	Fewer nodes than full PLND
Cystourethroscopy performed for separate diagnostic purpose	52000	Append modifier -59 or -XU
Urethral dilation at same session (unrelated)	53600-53665	Only if distinct separate service
Robotic assistance HCPCS code	S2900	Facility use only; not Medicare-payable; some commercial payers
Postoperative complications requiring return to OR	Appropriate surgical code + modifier -78	Within global period
Unrelated E/M during global	Appropriate E/M + modifier -24	Must be unrelated to surgery
Staged procedure during global	Appropriate procedure code + modifier -58	Planned/staged
Conversion to open (if converted mid-case)	55840, 55845 + modifier -53 on 55866	Rare; document reason thoroughly

🔴 Pelvic Lymph Node Dissection — Critical Add-On Consideration

This is one of the most important separately reportable services in radical prostatectomy coding:

CPT	Description	When to Use
38571	Laparoscopic bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes	Extended/standard bilateral PLND performed laparoscopically at same session as 55866
38572	Laparoscopic bilateral pelvic lymphadenectomy + peritoneal evaluation + diaphragm/pelvic washings	If washings and peritoneal evaluation are also performed
38562	Limited pelvic and para-aortic lymph node sampling	Sentinel or sampling only, not full PLND

✅ Billing Tip: 38571 is separately payable with 55866 per CMS and is not bundled under NCCI edits when a true pelvic lymphadenectomy is performed. Documentation must clearly describe the extent of the dissection: the obturator fossa, external iliac, and hypogastric (internal iliac) nodal packets must all be mentioned to support 38571.

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🌿 Code Tree / Family

Male Genital System - Prostate - Radical Prostatectomy (55801-55866)
│
├── 55801  Prostatectomy; perineal, subtotal (including nerve-sparing)
│
├── 55810  Prostatectomy; radical perineal
├── 55812  Prostatectomy; radical perineal, with lymph node biopsy(s)
├── 55815  Prostatectomy; radical perineal, with bilateral pelvic
│              lymphadenectomy, incl. external iliac, hypogastric, obturator
│
├── 55840  Prostatectomy; retropubic radical, w/ or w/o nerve sparing
├── 55842  Prostatectomy; retropubic radical, with lymph node biopsy(s)
├── 55845  Prostatectomy; retropubic radical, with bilateral pelvic
│              lymphadenectomy, incl. external iliac, hypogastric, obturator
│
└── 55866  ◀ YOU ARE HERE
               Laparoscopy, surgical prostatectomy, radical, retropubic,
               including nerve sparing; includes robotic assistance
               when performed
               ├── May add: 38571 - Laparoscopic bilateral pelvic
               │           lymphadenectomy (separately reportable)
               └── May add: 38572 - Laparoscopic bilateral pelvic
                           lymphadenectomy with peritoneal evaluation

📌 Open vs. Laparoscopic/Robotic Comparison

Approach	CPT Code	Nerve Sparing Included?	PLND Included?
Open retropubic, no PLND	55840	✅ Yes (descriptor)	❌ No
Open retropubic, node biopsy	55842	✅ Yes	Limited only
Open retropubic, full bilateral PLND	55845	✅ Yes	✅ Yes - bundled
Open perineal radical	55810	❌ No	❌ No
Open perineal + node biopsy	55812	❌ No	Limited only
Open perineal + full bilateral PLND	55815	❌ No	✅ Yes - bundled
Laparoscopic/Robotic	55866	✅ Yes - bundled	❌ Separately reportable

⚠️ Key Distinction: Unlike open codes 55845 and 55815, which bundle bilateral pelvic lymphadenectomy into the code itself, 55866 does NOT include PLND. When PLND is performed laparoscopically alongside 55866, it is separately reported with 38571 or 38572.

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🏥 ICD-10-CM Commonly Paired Diagnoses

🔴 Primary — Prostate Cancer (Most Common Indication)

ICD-10-CM	Description	HCC	Notes
C61	Malignant neoplasm of prostate	✅ HCC 12	Primary indication for radical prostatectomy in nearly all cases

C61 is the overwhelmingly dominant diagnosis for 55866. Radical prostatectomy is a curative-intent surgery performed for clinically localized or locally advanced prostate cancer. Other diagnoses rarely drive this procedure.

🔴 Staging / Risk Stratification Context Diagnoses

ICD-10-CM	Description	HCC	Notes
Z17.39	Other contact with and (suspected) exposure to other hazardous substances	❌ No	Rarely applicable
Z80.42	Family history of prostate cancer	❌ No	Secondary/supplemental; documents risk
Z85.46	Personal history of malignant neoplasm of prostate	❌ No	Post-treatment — use AFTER prostatectomy for follow-up visits; do NOT use as active cancer code

🔴 Incontinence / Sexual Dysfunction — Post-Prostatectomy (Global Period & Follow-Up)

The following are commonly used during the 90-day global period or follow-up after 55866 but are bundled unless separately documented as unrelated or staged:

ICD-10-CM	Description	HCC	Notes
N39.3	Stress incontinence (male)	❌ No	Post-prostatectomy urinary incontinence
N39.41	Urge incontinence	❌ No	Post-op overactive bladder
N52.01	Erectile dysfunction due to arterial insufficiency	❌ No	Post-nerve sparing; vascular etiology
N52.02	Corporo-venous occlusive erectile dysfunction	❌ No	Post-nerve sparing; venogenic
N52.03	Combined arterial insufficiency and corporo-venous occlusive ED	❌ No	Most common post-RP ED mechanism
N52.9	Male erectile dysfunction, unspecified	❌ No	Use only if etiology not documented

🔴 Intraoperative / Perioperative Complications

ICD-10-CM	Description	HCC	Notes
N99.510	Cystostomy hemorrhage	❌ No	Post-op bleeding at anastomosis
T81.32XA	Disruption of internal operation wound, not elsewhere classified, initial encounter	❌ No	Anastomotic leak
N13.8	Other obstructive and reflux uropathy	❌ No	Post-op stricture/obstruction
N35.812	Other urethral stricture, male, membranous urethra	❌ No	Vesicourethral anastomotic stricture
R33.9	Retention of urine, unspecified	❌ No	Post-catheter removal retention

🔴 Lymph Node Pathology (When PLND Performed Concurrently)

ICD-10-CM	Description	HCC	Notes
C77.5	Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes	✅ HCC 8	Lymph node metastases found on PLND — significant HCC impact
D36.0	Benign neoplasm of lymph nodes	❌ No	Rare; benign nodal pathology

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💡 HCC Details

C61 - Malignant Neoplasm of Prostate → HCC 12

Field	Detail
HCC Category	HCC 12 — Prostate, Testicular, and Other Male Genital Cancers
CMS-HCC Model	Version 28 (current)
RAF Score	~0.149 (community, non-dual)
Clinical Significance	Flags patient as high-complexity for risk-adjusted payment models
Documentation Requirement	Must be documented as active malignancy; surgical treatment (prostatectomy) confirms active cancer status
Post-Surgery Coding	After prostatectomy with clear margins: transition to Z85.46 (personal history) at appropriate follow-up once oncologist documents no evidence of disease (NED)
PSA Recurrence	If PSA rises post-prostatectomy: R97.21 (rising PSA after treatment) ± C61 if recurrence confirmed

C77.5 - Secondary Malignant Neoplasm, Intrapelvic Lymph Nodes → HCC 8

Field	Detail
HCC Category	HCC 8 — Metastatic Cancer and Acute Leukemia
RAF Score	~2.659 (community, non-dual) — extremely high RAF impact
Clinical Significance	Node-positive prostate cancer (pN1) dramatically increases risk score
Documentation Requirement	Requires pathology confirmation of lymph node metastases; intraoperative frozen section or final pathology
Code Pairing	Always code C61 + C77.5 together when pelvic node metastases are confirmed — C61 is the primary site, C77.5 is the secondary

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🔧 Applicable Modifiers

Modifier	Description	Application to 55866
-80	Assistant Surgeon	Primary assistant surgeon (MD/DO); reimbursed at ~16% of allowable
-81	Minimum Assistant Surgeon	Second assistant with limited participation; less common for RARP
-AS	PA/NP/CNS as Assistant Surgeon	Bedside assistant (non-physician); commonly used for robotic bedside assistant
-62	Two Surgeons	When two surgeons of different specialties perform distinct portions (rare for RARP; occasionally used if urologic oncologist + reconstructive surgeon)
-22	Increased Procedural Services	Exceptional complexity (e.g., prior pelvic radiation, prior TURP, morbid obesity, salvage RP); must be documented with detailed operative note explaining increased time/difficulty
-52	Reduced Services	Procedure substantially less than typically required (e.g., aborted prior to anastomosis)
-53	Discontinued Procedure	Procedure stopped due to medical emergency (e.g., cardiac event intraoperatively)
-58	Staged Procedure	Subsequent procedure planned/staged within global (e.g., continent diversion performed later)
-78	Unplanned Return to OR	Return for complication within global period (e.g., anastomotic leak requiring repair)
-79	Unrelated Procedure During Global	Completely unrelated surgery within 90-day global
-24	Unrelated E/M During Global	Postop office visit for unrelated condition
-32	Mandated Services	Workers’ comp or other mandated service contexts
-GA	Waiver of Liability on File	ABN-related; rarely applicable for cancer surgery
-LT / -RT	Left/Right Side	Not typically applicable to prostate (midline organ); may apply if nerve sparing documented unilaterally for billing documentation purposes

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🏨 MS-DRG (Inpatient)

55866 is frequently performed as an inpatient procedure, particularly when PLND is performed concurrently, robotic time is extended, or the patient’s comorbidity burden warrants overnight or 23-hour observation/admission. For inpatient admissions, the ICD-10-PCS procedure code is reported on the UB-04.

ICD-10-PCS Equivalents

ICD-10-PCS	Description	Notes
0VT04ZZ	Resection of Prostate, Percutaneous Endoscopic	Primary PCS code for robotic/laparoscopic radical prostatectomy
0VT07ZZ	Resection of Prostate, Via Natural or Artificial Opening	Rarely used for RP
07BC4ZX	Excision of Pelvic Lymphatic, Percutaneous Endoscopic, Diagnostic	Laparoscopic pelvic lymph node sampling (diagnostic/biopsy)
07BC4ZZ	Excision of Pelvic Lymphatic, Percutaneous Endoscopic	Laparoscopic pelvic lymphadenectomy (therapeutic/staging)
07BB4ZZ	Excision of Left Inguinal Lymphatic, Percutaneous Endoscopic	If extended dissection performed

PCS Root Operation for Radical Prostatectomy: Resection (T) — cutting out or off, without replacement, all of a body part. This distinguishes from Excision (B), which is partial. A radical prostatectomy removes the entire prostate gland; therefore, Resection is the correct root operation.

PCS Root Operation for Pelvic Lymph Node Dissection: Excision (B) with qualifier Z (No Qualifier) for therapeutic, or X (Diagnostic) for sampling/biopsy.

MS-DRG Assignment

MS-DRG	Description	Type	Typical Scenario
715	Other Male Reproductive System O.R. Procedures for Malignancy with MCC	Surgical	C61 + MCCs (e.g., respiratory failure, sepsis, C77.5)
716	Other Male Reproductive System O.R. Procedures for Malignancy with CC	Surgical	C61 + CCs (e.g., N40.1, E11.9, I10)
717	Other Male Reproductive System O.R. Procedures for Malignancy without CC/MCC	Surgical	C61 only, no significant comorbidities
729	Other Male Reproductive System O.R. Procedures with MCC	Surgical	If principal dx is not malignancy-related
730	Other Male Reproductive System O.R. Procedures with CC	Surgical	Non-malignancy principal dx with CC
731	Other Male Reproductive System O.R. Procedures without CC/MCC	Surgical	Non-malignancy, no comorbidities

🏥 Inpatient Coder Note — MS-DRG Optimization Tips:

• C61 as principal diagnosis routes to the 715-717 DRG triplet (malignancy-specific), which typically carries higher relative weights than the 729-731 triplet
• C77.5 (pelvic lymph node metastases, confirmed on PLND) codes as an MCC in many grouper versions — this alone can move a case from DRG 717 → 715, significantly impacting reimbursement
• Comorbidities such as E11.9 (Type 2 DM), I10 (hypertension), N17.9 (acute kidney injury), and J44.1 (COPD exacerbation) may qualify as CCs or MCCs, impacting DRG assignment
• Ensure the attending physician documents all comorbidities managed during the stay — query for conditions such as perioperative hypertensive urgency, blood transfusion indications, and post-op urinary retention as these may carry CC/MCC status
• Prolonged LOS alone does not change the DRG — focus on documented and coded CCs/MCCs

DRG Relative Weights (Approximate — FY2025)

MS-DRG	Relative Weight	Geometric Mean LOS
715	~4.2	~6.5 days
716	~2.4	~3.8 days
717	~1.5	~2.1 days

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📝 Coding Examples

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🟢 Example 1 - Standard Robotic Radical Prostatectomy, Organ-Confined Disease, No PLND

Clinical Scenario: A 58-year-old male with Gleason 7 (3+4) prostate cancer, clinical stage T2bN0M0, PSA 8.4. Low-intermediate risk. Robot-assisted laparoscopic radical prostatectomy performed with bilateral nerve sparing. No pelvic lymph node dissection performed (low-intermediate risk, Briganti nomogram <5% LN involvement). Estimated blood loss 150 mL. Specimen sent to pathology; final path: pT2c, Gleason 3+4=7, negative margins, seminal vesicles negative.

CPT Codes (Professional/Outpatient ASC):

• 55866 - Laparoscopic robotic radical prostatectomy with nerve sparing

ICD-10-CM:

• C61 - Malignant neoplasm of prostate (primary indication)

Inpatient UB-04 (ICD-10-PCS):

• Principal Dx: C61
• Procedure: 0VT04ZZ - Resection of Prostate, Percutaneous Endoscopic

MS-DRG: 717 (no CCs/MCCs) or 716 if comorbidities documented and coded

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🟢 Example 2 - Robotic Radical Prostatectomy WITH Bilateral Pelvic Lymphadenectomy

Clinical Scenario: A 63-year-old male with Gleason 4+4=8 (Grade Group 4) prostate cancer, clinical T3aN0M0, PSA 18.2. High-risk disease. RARP performed with bilateral nerve-sparing attempt on left side (non-nerve sparing on right per intraoperative findings). Bilateral extended pelvic lymph node dissection performed, removing external iliac, obturator fossa, and hypogastric nodal packets bilaterally. Final path: pT3a, Gleason 4+4, left margin positive, 2/18 pelvic lymph nodes positive for metastatic adenocarcinoma.

CPT Codes:

• 55866 - RARP with nerve sparing (unilateral attempt; bilateral descriptor still applies)
• 38571 - Laparoscopic bilateral pelvic lymphadenectomy (separately reportable; PLND not included in 55866)

ICD-10-CM:

• C61 - Malignant neoplasm of prostate
• C77.5 - Secondary malignant neoplasm of intrapelvic lymph nodes (confirmed on pathology)

Inpatient UB-04 (ICD-10-PCS):

• Principal Dx: C61
• Secondary Dx: C77.5 ← MCC — routes to DRG 715
• Procedures:
  • 0VT04ZZ - Resection of Prostate, Percutaneous Endoscopic
  • 07BC4ZZ - Excision of Pelvic Lymphatic (bilateral), Percutaneous Endoscopic

MS-DRG: 715 (malignancy + MCC from C77.5)

💡 Coder Note: The positive lymph nodes (C77.5) discovered intraoperatively or on final pathology must be coded on the inpatient claim when confirmed during that admission. C77.5 as an MCC dramatically impacts DRG weight and reimbursement — do not miss this.

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🟢 Example 3 - Robotic RP with Increased Complexity (Prior TURP, Obesity)

Clinical Scenario: A 71-year-old male with known prostate cancer (C61), Gleason 7 (4+3), prior transurethral resection of prostate (TURP) 4 years ago, BMI 42 (morbid obesity). RARP performed; surgery required 6.5 hours due to extensive adhesions from prior TURP, obliterated tissue planes, and obesity-related technical difficulty. Operative note explicitly documents “significantly increased operative time, complexity, and risk due to prior TURP scarring and morbid obesity.”

CPT Codes:

• 55866 - -22 - RARP with increased procedural services (modifier -22 requires documentation of unusual complexity and will likely require a cover letter to payer)

ICD-10-CM:

• C61 - Malignant neoplasm of prostate
• E66.01 - Morbid (severe) obesity due to excess calories (documents medical necessity for modifier -22)
• Z87.891 - Personal history of other specified conditions (prior TURP)

Note: Modifier -22 should be submitted with a cover letter explaining the unusual circumstances. CMS does not have a specific process for -22 but allows it; commercial payers vary. Expect 10-30% additional reimbursement consideration if approved.

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🟢 Example 4 - Inpatient Admission, Return to OR Within Global (Anastomotic Leak)

Clinical Scenario: Patient underwent RARP on Day 1 of admission. Discharged POD2. Readmitted POD5 with pelvic abscess and anastomotic leak. Return to OR for laparoscopic washout and drain placement.

CPT Codes (Return to OR):

• 49323 - Laparoscopy, surgical; with drainage of lymphocele or cyst (if lymphocele) — or appropriate laparoscopic washout code
• Append modifier -78 - Unplanned return to OR for complication during global period

ICD-10-CM:

• T81.32XD - Disruption of internal operation wound, subsequent encounter
• C61 - Underlying reason for original surgery (active malignancy)
• K65.1 - Peritoneal abscess (pelvic)

Inpatient Note: Second admission is a separate encounter; code the complication as principal diagnosis for the second admission. C61 is secondary.

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🟢 Example 5 - Assistant Surgeon Billing (Bedside Robotic Assistant)

Clinical Scenario: PA-C serves as bedside assistant during RARP. Attending urologist operates at robotic console. PA-C manages instruments at bedside, assists with exposure, and manages specimen extraction.

CPT Code (PA billing):

• 55866 - -AS - Physician assistant as assistant at surgery

ICD-10-CM:

• C61 - Malignant neoplasm of prostate

Payment: Medicare reimburses -AS modifier at 85% of the 16% assistant surgeon allowable = approximately 13.6% of the primary surgeon’s allowed amount. Commercial payers vary widely.

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⚠️ Common Coding Pitfalls

• ❌ Do not separately bill for robotic assistance (e.g., S2900) on the professional claim — it is bundled into 55866 by AMA descriptor; most payers will deny S2900 as a professional service
• ❌ Do not assume PLND is included in 55866 — unlike open codes 55845/55815, laparoscopic PLND is separately reportable with 38571 or 38572
• ❌ Do not use 55840 (open retropubic RP) for a robotic case — even if documentation says “retropubic approach,” if it was performed laparoscopically/robotically, 55866 is correct
• ❌ Do not bill 55866 + 55840 together — they represent the same procedure via different approaches; report only one
• ❌ Do not code Z85.46 (personal history of prostate cancer) during the same admission as the radical prostatectomy — C61 is the active cancer being treated
• ✅ Always query the surgeon regarding nerve sparing laterality — while both unilateral and bilateral are bundled into 55866, documentation of nerve sparing affects prognostic coding and clinical completeness
• ✅ Always review the final pathology report for lymph node status — positive nodes (C77.5) carry HCC 8 status and MS-DRG MCC designation; missed diagnosis = significant undercoding
• ✅ Verify the operative note documents “percutaneous endoscopic” or “laparoscopic” approach for PCS — 0VT04ZZ requires the 4th character = 4 (Percutaneous Endoscopic); a hand-assisted laparoscopic approach may require a different character value
• ✅ Modifier -22 requires both a detailed operative note AND typically a cover letter — submit proactively with the claim rather than waiting for a denial
• ✅ During the 90-day global period, routine follow-up visits are bundled; only separately billable encounters are those for unrelated conditions (-24), staged procedures (-58), or complications requiring OR return (-78)

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📌 Quick Reference Summary

Field	Value
Code	55866
Type	CPT - Surgical (Major)
System	Male Genital
Body Part	Prostate (entire)
Approach	Laparoscopic / Robotic-Assisted
Robotic Inclusive	✅ Yes
Nerve Sparing Inclusive	✅ Yes (uni or bilateral)
PLND Inclusive	❌ No — bill 38571/38572 separately
Global Period	090 (90 days)
wRVU (Fac/Non-Fac)	34.25
Assistant Payable	✅ Yes — 80, 81, AS
Modifier 22 Eligible	✅ Yes — with documentation
PCS Equivalent	0VT04ZZ
Primary DX	C61 → HCC 12
Node Met DX	C77.5 → HCC 8 (MCC)
MS-DRG (Malignancy)	715 / 716 / 717
MS-DRG (Non-Malig)	729 / 730 / 731

A few highlights specific to 55866 worth noting for your workflow:

• The PLND distinction (bundled in open codes, separately reportable in 55866) is the single most impactful billing nuance for this code — it catches a lot of coders off guard
• The C77.5 → HCC 8 / MCC pathway is a high-value documentation opportunity that often goes uncoded when the PLND is performed but node-positive results come back after discharge
• The PCS root operation distinction (Resection vs. Excision) for inpatient coding is critical — the whole gland = Resection (T), not Excision (B)

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_{AMA CPT Professional Edition 2024 · CMS Physician Fee Schedule Look-Up Tool FY2025 · CMS-HCC Risk Adjustment Model v28 · CMS NCCI Policy Manual for Medicare Services v30 · AHA Coding Clinic for ICD-10-CM/PCS · CMS ICD-10-PCS Official Guidelines for Coding and Reporting FY2025 · CMS MS-DRG Grouper v41 · CMS IPPS Final Rule FY2025 · ACS NSQIP Prostatectomy Outcomes Data}