How To Use CPT Code 53230

CPT 53230 describes the excision of a urethral diverticulum in female patients as a separate procedure. 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 53230?

CPT 53230 is used to describe the excision of a urethral diverticulum in female patients. This procedure involves the removal of an abnormal pouch that opens from the bladder or other hollow organ. The purpose of the excision is to improve urination and relieve pain in the patient.

2. Official Description

The official description of CPT code 53230 is: ‘Excision of urethral diverticulum (separate procedure); female.’

3. Procedure

1. During the procedure, the provider makes a longitudinal incision into the anterior vaginal wall to access the urethra and the urethral diverticulum.
2. The incision is extended down to the level of the urethra, and the diverticulum is identified.
3. The provider then dissects the diverticular neck from the vaginal wall and the urethral attachment, separating the diverticulum.
4. The dissected diverticular pouch is removed, and the defect is closed with sutures.
5. A catheter may be inserted into the urethra to promote healing and is typically removed at a later date.
6. The provider ensures any bleeding is controlled and sutures the vaginal wall in a simple or layered fashion.

4. Qualifying circumstances

CPT 53230 is performed on female patients who have a urethral diverticulum that requires excision. The procedure is indicated to improve urination and relieve pain. It is important to note that this code is specific to female patients. For the excision of a urethral diverticulum in male patients, use code 53235.

5. When to use CPT code 53230

CPT code 53230 should be used when a provider performs the excision of a urethral diverticulum as a separate procedure in a female patient. It is important to ensure that the procedure is performed on a female patient and not a male patient, as there is a separate code for male patients (53235).

6. Documentation requirements

To support a claim for CPT code 53230, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a urethral diverticulum
• Description of the procedure performed, including the incision made, dissection of the diverticular neck, removal of the diverticular pouch, and closure of the defect
• Date of the procedure
• Any additional details or complications encountered during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 53230, ensure that the procedure is performed on a female patient. Use code 53235 for the excision of a urethral diverticulum in male patients. It is important to follow the specific documentation requirements and include all necessary details to support the claim. Additionally, be aware of any specific payer guidelines or modifiers that may be required for accurate billing.

8. Historical information

CPT code 53230 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 excision of a urethral diverticulum in a female patient to alleviate her symptoms of urinary retention and pain.
2. A gynecologist performs the excision of a urethral diverticulum in a female patient who has been experiencing recurrent urinary tract infections.
3. A female patient presents with urinary incontinence and discomfort, and a urologist performs the excision of a urethral diverticulum to address these issues.
4. A patient with a known urethral diverticulum undergoes the excision procedure to relieve her symptoms of dysuria and pelvic pain.
5. A urologist performs the excision of a urethral diverticulum in a female patient who has been experiencing frequent urinary urgency and frequency.
6. A female patient with a large urethral diverticulum undergoes the excision procedure to improve her urinary flow and reduce the risk of recurrent infections.
7. A urologist performs the excision of a urethral diverticulum in a female patient who has been experiencing pain during sexual intercourse.
8. A patient with a symptomatic urethral diverticulum undergoes the excision procedure to alleviate her symptoms of urinary obstruction and discomfort.
9. A gynecologist performs the excision of a urethral diverticulum in a female patient who has been experiencing recurrent episodes of hematuria.
10. A female patient with a large urethral diverticulum undergoes the excision procedure to improve her quality of life and reduce the risk of complications.