How To Use CPT Code 53085

CPT 53085 describes the surgical procedure for draining perineal urinary extravasation, specifically in complicated cases. 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 53085?

CPT 53085 is used to report the surgical drainage of perineal urinary extravasation in complicated cases. It involves the removal of urine that has leaked into the perineal tissues, which may require more extensive dissection or suturing due to the size or complexity of the extravasation. The procedure aims to correct the leakage and alleviate any associated pain.

2. Official Description

The official description of CPT code 53085 is: ‘Drainage of perineal urinary extravasation; complicated.’

3. Procedure

1. After appropriate patient preparation and anesthesia, the healthcare provider makes an incision around the urethra to locate the site of extravasation.
2. Once identified, the incision is extended into the area of extravasation to drain the urine.
3. If the extravasation is large or diffuse, the procedure may require additional dissection or suturing to close the area.
4. The provider irrigates the area with antibiotic solution to prevent infection.
5. Any bleeding is controlled, and the incision is closed in layers using absorbable sutures.

4. Qualifying circumstances

CPT 53085 is used for cases of perineal urinary extravasation that are complicated, meaning they require more extensive dissection or suturing due to the size or complexity of the leakage. The procedure is performed to alleviate pain and correct the leakage. It is important to note that CPT 53085 should be used for complicated cases, while CPT 53080 is used for uncomplicated extravasation.

5. When to use CPT code 53085

CPT code 53085 should be used when performing the surgical drainage of perineal urinary extravasation in complicated cases. It is important to accurately document the complexity of the extravasation and the need for additional dissection or suturing to support the use of this code.

6. Documentation requirements

To support a claim for CPT 53085, the healthcare provider must document the following information:

• Description of the complicated nature of the perineal urinary extravasation
• Details of the surgical procedure performed, including the extent of dissection or suturing required
• Date of the procedure
• Any complications encountered during the procedure
• Postoperative care instructions, if applicable
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53085, ensure that the procedure meets the criteria for a complicated perineal urinary extravasation. It is important to accurately document the complexity of the case to support the use of this code. Additionally, be aware of any specific payer guidelines or modifiers that may be required for proper reimbursement.

8. Historical information

CPT 53085 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 urologist performs the surgical drainage of perineal urinary extravasation in a patient with a complex leakage, requiring extensive dissection and suturing.
2. A general surgeon drains perineal urinary extravasation in a patient with a large and diffuse leakage, necessitating additional dissection and suturing to close the area.
3. An interventional radiologist performs the surgical drainage of perineal urinary extravasation in a patient with a complicated leakage, using image guidance to locate and drain the urine.
4. A urogynecologist performs the surgical drainage of perineal urinary extravasation in a patient with a complex leakage, requiring meticulous dissection and suturing to correct the problem.
5. A colorectal surgeon drains perineal urinary extravasation in a patient with a complicated leakage, performing additional exploration and repair to ensure proper closure of the area.