How To Use CPT Code 53200

CPT 53200 describes the excision of tissue from the urethra for biopsy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53200?

CPT 53200 involves the removal of tissue from the urethra for biopsy. The provider makes a small incision in the suprapubic area to access the urethra and excises tissue from several sites using surgical forceps. This procedure is performed to determine the nature of a lesion in the urethra.

2. Official Description

The official description of CPT code 53200 is the excision of tissue from the urethra for biopsy. This code does not include the closure of the incision.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. A small longitudinal incision is made in the suprapubic area to access the urethra.
3. The provider dissects down to the level of fascia and muscle.
4. The suspicious area of the urethra is identified.
5. Tissue is excised from several sites in the urethra using surgical forceps.
6. Any bleeding is controlled, and the incision is closed in layers using absorbable sutures.

4. Qualifying circumstances

CPT 53200 is performed when there is a need to determine the nature of a lesion in the urethra. The patient must be appropriately prepped and anesthetized for the procedure. The provider must excise tissue from the urethra using surgical forceps.

5. When to use CPT code 53200

CPT code 53200 should be used when the provider performs an excision of tissue from the urethra for biopsy. This code should not be used if the closure of the incision is also performed.

6. Documentation requirements

To support a claim for CPT 53200, the provider must document the following information:

• Reason for the biopsy and the need to determine the nature of the lesion
• Details of the procedure, including the incision site and the use of surgical forceps
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53200, ensure that the excision of tissue from the urethra for biopsy is performed. Do not report CPT 53200 if closure of the incision is also performed. There are no specific guidelines regarding reporting CPT 53200 with other codes.

8. Historical information

CPT 53200 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A urologist performs an excision of tissue from the urethra for biopsy to determine the nature of a suspicious lesion.
2. A patient presents with recurrent urinary tract infections, and the urologist performs an excision of tissue from the urethra for biopsy to investigate the underlying cause.
3. A urologist discovers a suspicious mass during a cystoscopy and performs an excision of tissue from the urethra for biopsy to determine if it is cancerous.
4. A patient experiences urinary obstruction, and the urologist performs an excision of tissue from the urethra for biopsy to identify the cause of the obstruction.
5. A urologist performs an excision of tissue from the urethra for biopsy to investigate the presence of abnormal cells in a patient with hematuria.
6. A patient presents with urethral discharge, and the urologist performs an excision of tissue from the urethra for biopsy to diagnose the underlying infection.
7. A urologist performs an excision of tissue from the urethra for biopsy to determine the nature of a suspicious lesion in a patient with recurrent urethral strictures.
8. A patient with urinary incontinence undergoes an excision of tissue from the urethra for biopsy to investigate the cause of the condition.
9. A urologist performs an excision of tissue from the urethra for biopsy to determine the nature of a suspicious lesion in a patient with lower urinary tract symptoms.
10. A patient presents with urethral pain, and the urologist performs an excision of tissue from the urethra for biopsy to identify the cause of the pain.