How To Use CPT Code 51841

CPT 51841 describes a surgical procedure known as anterior vesicourethropexy or urethropexy. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51841?

CPT 51841 is a code used to describe a surgical procedure called anterior vesicourethropexy or urethropexy. This procedure involves the elevation and fixation of the bladder neck and urethra to restore the urethrovesical angle and treat urinary incontinence. It is typically performed when there are complicating factors such as extensive dissection of adhesions, excessive bleeding, or other complexities that require additional time.

2. Official Description

The official description of CPT code 51841 is: ‘Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair).’ This code is used when the procedure involves extensive dissection of adhesions, excessive bleeding, or other complicating factors that make it more complex than a simple vesicourethropexy.

3. Procedure

1. The patient is prepped and draped for the procedure.
2. A Foley catheter is inserted through the urethra and into the bladder to guide the procedure and collect urine.
3. The patient is placed in the supine position with knees bent (lithotomy position) and given suitable anesthesia.
4. The surgeon makes an incision, either transverse (Pfannenstiel) or vertical, over the lower pelvic area to access the bladder and urethra.
5. The surgeon identifies the bladder and urethrovaginal angle with the aid of the Foley catheter and inserts a finger into the vagina to locate the perivaginal and periurethral sites.
6. Sutures are placed in the perivaginal and periurethral tissues, avoiding blood vessels in the plexus of Santorini.
7. For the Marshall-Marchetti-Krantz (MMK) procedure, the sutures are tied to the periosteum of the pubic symphysis, creating a pubovesical cervical (PVC) fascia sling.
8. For the Burch procedure, the sutures are attached to the conjoined tendons or Cooper’s ligament, leaving a space between the ligament and periurethral tissue.
9. Additional sutures may be placed if necessary.
10. Bleeding vessels are fulgurated or tied off, and the incision is closed in layers.
11. The Foley catheter may be left in place until the patient can urinate on their own.

4. Qualifying circumstances

CPT 51841 is used when the anterior vesicourethropexy or urethropexy procedure is complicated by factors such as extensive dissection of adhesions, excessive bleeding, previous surgery, vaginal prolapse, secondary repair, or obesity. These circumstances make the procedure more challenging and time-consuming.

5. When to use CPT code 51841

CPT code 51841 should be used when the anterior vesicourethropexy or urethropexy procedure is complicated by factors that require additional time and effort. It should not be used for simple vesicourethropexy procedures without complicating factors.

6. Documentation requirements

To support a claim for CPT 51841, the documentation should include:

• Clear indication of the complicating factors that necessitate the use of this code
• Description of the procedure performed, including the approach used (transverse or vertical incision)
• Details of the suturing technique and location of sutures
• Documentation of any additional procedures performed, such as fulguration of bleeding vessels
• Record of the closure technique used
• Any other relevant details or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 51841, it is important to ensure that the procedure meets the criteria for a complicated anterior vesicourethropexy or urethropexy. This code should not be reported for simple vesicourethropexy procedures without complicating factors. It is also important to follow any specific billing guidelines provided by the payer or Medicare.

8. Historical information

CPT code 51841 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a complicated anterior vesicourethropexy procedure due to extensive adhesions from a previous surgery.
2. A surgeon performs an anterior vesicourethropexy with secondary repair for a patient who experienced recurrent urinary incontinence after a previous procedure.
3. An obese patient requires a complicated anterior vesicourethropexy procedure to address urinary incontinence.
4. A patient with vaginal prolapse undergoes a complicated anterior vesicourethropexy procedure to restore the urethrovesical angle.
5. A surgeon performs an anterior vesicourethropexy with extensive dissection of adhesions to treat urinary incontinence in a patient.