How To Use CPT Code 53010

CPT 53010 describes the procedure of urethrotomy or urethrostomy, specifically for the perineal urethra. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53010?

CPT 53010 is used to describe a surgical procedure performed on the perineal urethra to treat a stricture, which is a narrowing of the urethra. The provider makes an incision in the anterior part of the urethra to alleviate difficulty voiding for the patient.

2. Official Description

The official description of CPT code 53010 is: ‘Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external.’

3. Procedure

1. After appropriate prepping and anesthesia, the provider makes a stab transurethral incision.
2. A sound is passed through the urethra to identify the location of the urethral stricture.
3. The provider extends the incision beyond the identified stricture.
4. The stricture of the perineal urethra is dissected and released.
5. The provider removes the sound, sutures the urethra with surrounding tissue and fascia for proper suspension, controls any bleeding, and closes the incision in layers.

4. Qualifying circumstances

CPT 53010 is performed on patients with a stricture in the perineal portion of the urethra. The procedure is done to alleviate difficulty voiding. The perineal urethra is the narrowest part of the urethra, located deep in the perineal pouch. The provider must make an incision in the anterior part of the urethra to treat the stricture.

5. When to use CPT code 53010

CPT code 53010 should be used when the provider performs an external urethrotomy or urethrostomy specifically for the perineal urethra. It is important to note that if the incision is made in the pendulous urethra, a different code, such as 53000, should be used.

6. Documentation requirements

To support a claim for CPT 53010, the provider must document the following information:

• Patient’s diagnosis of urethral stricture and the need for the procedure
• Details of the procedure, including the incision made in the anterior part of the urethra and the dissection and release of the perineal urethral stricture
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53010, ensure that the procedure is performed on the perineal urethra and not the pendulous urethra. It is important to follow the specific documentation requirements and include the necessary details in the claim. Additionally, be aware of any specific guidelines or modifiers that may be required by the payer.

8. Historical information

CPT 53010 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a perineal urethral stricture undergoes an external urethrotomy to alleviate difficulty voiding.
2. A provider performs an external urethrostomy on a patient with a perineal urethral stricture to remove the obstruction.
3. A patient presents with difficulty voiding due to a perineal urethral stricture, and the provider performs an incision and dissection to release the stricture.
4. A provider performs an external urethrotomy on a patient with a perineal urethral stricture to improve urinary flow.
5. A patient with a perineal urethral stricture undergoes an external urethrostomy to relieve urinary obstruction.
6. A provider performs an incision and suturing procedure on the perineal urethra of a patient with a stricture to restore normal urinary function.
7. A patient with difficulty voiding due to a perineal urethral stricture undergoes an external urethrotomy to widen the urethral opening.
8. A provider performs an external urethrostomy on a patient with a perineal urethral stricture to create a new opening for urine to pass through.
9. A patient with a perineal urethral stricture undergoes an incision and dissection procedure to remove the narrowing and improve urinary flow.
10. A provider performs an external urethrotomy on a patient with a perineal urethral stricture to alleviate urinary retention.