How To Use CPT Code 0421T

CPT 0421T describes a procedure called transurethral waterjet ablation of the prostate, which is used to treat benign prostate hyperplasia (BPH) in older men. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0421T?

CPT 0421T is a code that represents a specific procedure called transurethral waterjet ablation of the prostate. This procedure is used to treat benign prostate hyperplasia (BPH), which is an enlargement of the prostate that commonly occurs in older men. It involves the use of ultrasound guidance and a robotic guidance system to deliver a high-velocity jet of saline through a catheter inserted into the urethra. The purpose of this procedure is to destroy (ablate) the prostate and alleviate symptoms such as urinary urgency, frequency, straining, weak flow, and incomplete bladder emptying.

2. Official Description

The official description of CPT code 0421T is: ‘Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).’ This code includes other procedures on the urethra and seminal vesicles when performed. It should not be reported in conjunction with codes 52500, 52630, or 76872.

3. Procedure

1. With the patient appropriately prepped and anesthetized, the provider uses real-time ultrasound guidance to perform transurethral waterjet ablation of the prostate.
2. A preprogrammed robotically guided high-velocity jet of saline is delivered through a cystoscope placed through the urethra to destroy the prostate.
3. The provider collects prostatic tissue for analysis if necessary.
4. If there is any post-operative bleeding, the provider controls it using a low-pressure water stream encompassing a low-power laser beam.
5. The provider removes the cystoscope, which is a tubular lighted instrument used to examine the interior of the urinary bladder and ureter.
6. Other procedures, such as vasectomy, meatotomy, cystourethroscopy, urethral calibration, dilation, and internal urethrotomy, may be performed as part of the ablation procedure.

4. Qualifying circumstances

CPT code 0421T is used for patients who have benign prostate hyperplasia (BPH) and require transurethral waterjet ablation of the prostate. This procedure is typically performed on older men who experience symptoms such as urinary urgency, frequency, straining, weak flow, and incomplete bladder emptying. The procedure is performed by a provider using ultrasound guidance and a robotic guidance system. Other procedures on the urethra and seminal vesicles may be performed as part of the ablation procedure.

5. When to use CPT code 0421T

CPT code 0421T should be used when a provider performs transurethral waterjet ablation of the prostate using ultrasound guidance and a robotic guidance system. This code should not be reported in conjunction with codes 52500, 52630, or 76872.

6. Documentation requirements

To support a claim for CPT code 0421T, the provider must document the following information:

• Patient’s diagnosis of benign prostate hyperplasia (BPH)
• Use of ultrasound guidance and a robotic guidance system
• Date of the procedure
• Details of the procedure, including the use of a high-velocity jet of saline and any additional procedures performed
• Control of post-operative bleeding, if applicable
• Signature of the provider

7. Billing guidelines

When billing for CPT code 0421T, ensure that the procedure meets the criteria outlined in the official description. Do not report this code in conjunction with codes 52500, 52630, or 76872. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT code 0421T was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A provider performs transurethral waterjet ablation of the prostate using ultrasound guidance and a robotic guidance system to treat a patient with benign prostate hyperplasia (BPH).
2. During the procedure, the provider also performs a vasectomy and urethral calibration.
3. Another provider performs transurethral waterjet ablation of the prostate and controls post-operative bleeding using a low-pressure water stream and a low-power laser beam.
4. A patient with symptoms of urinary urgency, frequency, and weak flow undergoes transurethral waterjet ablation of the prostate to alleviate their symptoms.
5. A provider performs transurethral waterjet ablation of the prostate on an older man with benign prostate hyperplasia (BPH) using ultrasound guidance and a robotic guidance system.
6. During the procedure, the provider also performs a meatotomy and cystourethroscopy.
7. Another provider performs transurethral waterjet ablation of the prostate and collects prostatic tissue for analysis.
8. A patient with incomplete bladder emptying undergoes transurethral waterjet ablation of the prostate to improve their condition.
9. A provider performs transurethral waterjet ablation of the prostate and controls post-operative bleeding using a low-pressure water stream and a low-power laser beam.
10. During the procedure, the provider also performs urethral dilation and internal urethrotomy.