How To Use CPT Code 53235

CPT 53235 describes the excision of a urethral diverticulum in male 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 53235?

CPT 53235 is used to describe the excision of a urethral diverticulum in male patients as a separate procedure. This code is specifically for male patients, and there is a separate code for female patients (CPT 53230). The procedure involves making an incision in the suprapubic area to remove the diverticulum, improving urination and relieving pain.

2. Official Description

The official description of CPT code 53235 is: ‘Excision of urethral diverticulum (separate procedure); male.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. A longitudinal transurethral incision is made in the suprapubic area to access the urethra and the urethral diverticulum.
3. The incision is extended down to the level of the urethra, and the diverticulum is identified.
4. The provider dissects the diverticular neck from the urethral attachment and separates the diverticulum.
5. The dissected diverticular pouch is removed, and the remaining defect in the urethra is sutured.
6. A catheter may be inserted into the urethra to promote healing and is typically removed at a later date.
7. Any bleeding is controlled, and the incision is sutured in a simple or layered fashion.

4. Qualifying circumstances

CPT 53235 is performed on male patients who have a urethral diverticulum that requires excision. A urethral diverticulum is an abnormal pouch that opens from the urethra. The procedure is done to improve urination and relieve pain. It is important to note that there is a separate code for the excision of urethral diverticulum in female patients (CPT 53230).

5. When to use CPT code 53235

CPT code 53235 should be used when a male patient undergoes a separate procedure to excise a urethral diverticulum. It is important to use the correct code for male patients, as there is a separate code for female patients (CPT 53230).

6. Documentation requirements

To support a claim for CPT 53235, the provider must document the following information:

• Patient’s diagnosis of a urethral diverticulum
• Details of the procedure, including the incision made, the removal of the diverticulum, and the suturing of the urethra
• Use of a catheter, if applicable
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53235, ensure that the procedure is performed on a male patient as a separate procedure for the excision of a urethral diverticulum. It is important to use the correct code for female patients (CPT 53230) if the procedure is performed on a female patient. There are no specific guidelines regarding reporting CPT 53235 with other codes. However, it is important to follow any applicable bundling or unbundling rules and to provide appropriate documentation to support the claim.

8. Historical information

CPT 53235 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 a urethral diverticulum in a male patient to improve urination and relieve pain.
2. A patient presents with a urethral diverticulum, and the provider performs a separate procedure to remove the diverticulum and suture the urethra.
3. A male patient undergoes an excision of a urethral diverticulum as a separate procedure to address urinary symptoms and discomfort.
4. A urologist performs an excision of a urethral diverticulum in a male patient to alleviate pain and improve urinary flow.
5. A patient with a urethral diverticulum undergoes a separate procedure to have the diverticulum excised and the urethra repaired.
6. A urologist performs an excision of a urethral diverticulum in a male patient to address urinary obstruction and discomfort.
7. A male patient presents with a urethral diverticulum, and the provider performs a separate procedure to remove the diverticulum and suture the urethra.
8. An excision of a urethral diverticulum is performed as a separate procedure in a male patient to alleviate symptoms and improve urinary function.
9. A urologist performs an excision of a urethral diverticulum in a male patient to relieve pain and improve urinary flow.
10. A patient undergoes a separate procedure to have a urethral diverticulum excised and the urethra repaired, addressing urinary symptoms and discomfort.