CPT 55865: Perineal Prostate Incision with Lymph Node Sampling - OpenPayer

Summary & Overview

CPT 55865: Perineal Prostate Incision with Lymph Node Sampling

CPT code 55865 represents a surgical perineal approach to the prostate to permit placement of radioactive material (brachytherapy) for malignant prostate cancer, combined with bilateral sampling of iliac, hypogastric, and obturator lymph nodes. This procedure is clinically significant because it facilitates definitive local prostate cancer therapy while providing staging information through lymph node pathology, which can affect subsequent treatment decisions.

Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find national benchmarks and coverage context for CPT code 55865, clinical context regarding its role in prostate cancer management, and notes on typical sites of service. The publication outlines expected service components, common billing modifiers included in input data, and areas where policy or coverage variability may influence authorization and payment. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 55865prostate surgerybrachytherapy accesslymph node samplingurologysurgical oncologyoperating roomambulatory surgerypathology submission

Billing Code Overview

CPT code 55865 describes a surgical procedure in which the provider performs a perineal incision to expose the prostate to enable insertion of radioactive material for treatment of malignant prostate cancer. The procedure includes sampling of adjacent iliac, hypogastric, and obturator lymph nodes on both sides of the pelvis with submission of the specimens to a laboratory for analysis.

Service type: Surgical prostate procedure with lymph node sampling
Typical site of service: Hospital operating room or ambulatory surgical center

Clinical & Coding Specifications

Clinical Context

A 68-year-old man with biopsy-proven adenocarcinoma of the prostate (intermediate-to-high risk) is scheduled for a radical perineal prostate brachytherapy procedure with pelvic lymph node sampling. The patient presents to an ambulatory surgical center or hospital operating room after preoperative evaluation including PSA, cross-sectional pelvic imaging, and anesthetic assessment. Under general or regional anesthesia, the urologic surgeon makes a perineal incision to expose the prostate and place permanent or temporary radioactive seeds; a radiation oncologist may place the radioactive material. Concurrently, the surgeon performs bilateral sampling of iliac, hypogastric (internal iliac), and obturator lymph nodes and sends specimens to pathology for frozen section and final analysis. Typical intraoperative workflow includes preoperative antibiotic administration, urinary catheter placement, perineal incision and prostate exposure, seed insertion/coordination with radiation oncology, lymph node dissection or sampling, hemostasis, and wound closure. Postoperative care includes immediate recovery in PACU, pain control, monitoring for urinary retention or bleeding, and instructions for activity restrictions and follow-up with urology and radiation oncology for pathology review and adjuvant therapy planning.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier (default)	Use when no modifier applies and billing is routine.

CPT 55862: Perineal Prostate Access for Brachytherapy with Lymph Node Sampling

cpt-55845-radical-prostatectomy-with-pelvic-lymph-node-dissection

CPT 55845: Radical Prostatectomy with Pelvic Lymph Node Dissection

cpt-55815-perineal-prostatectomy-with-lymph-node-dissection

CPT 55815: Perineal Prostatectomy with Lymph Node Dissection

cpt-55840-radical-retropubic-prostatectomy

CPT 55840: Radical Retropubic Prostatectomy

cpt-55860-perineal-access-for-prostate-brachytherapy

CPT 55860: Perineal Access for Prostate Brachytherapy

cpt-55831-open-prostatectomy-lower-abdominal-approach

CPT 55831: Open Prostatectomy via Lower Abdominal Approach

cpt-55821-open-prostatectomy-lower-abdominal-approach

CPT 55821: Open Prostatectomy via Lower Abdominal (Suprapubic) Approach

cpt-55842-radical-prostatectomy-with-pelvic-lymph-node-removal

CPT 55842: Radical Prostatectomy with Pelvic Lymph Node Removal

cpt-55801-perineal-prostatectomy-for-obstructive-prostate-disease

CPT 55801: Perineal Prostatectomy for Obstructive Prostate Disease

cpt-55812-radical-perineal-prostatectomy

CPT 55812: Radical Perineal Prostatectomy for Prostate Cancer

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Taxonomy Code	Specialty	Notes
208800000X	Urology	Primary specialty performing perineal prostate exposure, lymph node sampling, and coordination with radiation oncology.
2084P0800X	Radiation Oncology	Responsible for placement of radioactive material (brachytherapy seeds) and treatment planning.
207RR0500X	General Surgery	May assist with pelvic lymph node dissection when complex pelvic anatomy or prior surgery present.
364S00000X	Pathology	Receives and processes lymph node specimens for intraoperative frozen section and final diagnosis.
207L00000X	Colon & Rectal Surgery	May be involved when perineal approach or pelvic floor reconstruction is complex.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C61`	Malignant neoplasm of prostate	Primary indication for prostate brachytherapy and pelvic lymph node sampling.
`N40.1`	Benign prostatic hyperplasia with lower urinary tract symptoms	Common comorbidity affecting surgical planning and perioperative urinary management.
`D07.5`	Carcinoma in situ of prostate (intraductal)	May be encountered in diagnostic workup and influence extent of treatment.
`C79.82`	Secondary malignant neoplasm of pelvic lymph node(s)	Relevant when nodal metastasis is suspected and sampling is performed to stage disease.
`Z85.46`	Personal history of malignant neoplasm of prostate	Relevant for surveillance cases or recurrent disease planning.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`55866`	Laparoscopic radical prostatectomy (or radical retropubic prostatectomy with pelvic lymphadenectomy, when listed separately)	Alternative surgical approach to prostate removal; pelvic lymph node dissection overlaps anatomically with lymph node sampling described in `55865`.
`38500`	Biopsy or excision of lymph node(s); open, superficial	May be reported when discrete superficial lymph nodes are excised separately rather than sampled during pelvic dissection.
`38700`	Lymphadenectomy, open, retroperitoneal or pelvic (separate procedure)	Reported when an extended pelvic lymph node dissection is performed in conjunction with prostate procedure.
`55810`	Transurethral resection of prostate; simple (separate benign procedure)	May be performed previously or concurrently for obstructive symptoms but is a different procedure set.
`50020`	Insertion of percutaneous or transperineal implantable brachytherapy source (example code)	Represents the brachytherapy component usually performed by a radiation oncologist in coordination with the perineal approach described in `55865`.

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