How To Use CPT Code 53240

CPT 53240 describes the marsupialization of a urethral diverticulum in both male and female patients. 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 53240?

CPT 53240 is used to describe the surgical procedure of marsupialization for a urethral diverticulum. This procedure involves creating an opening in the diverticulum by making a surgical incision. The purpose of this procedure is to improve urination and relieve pain in both male and female patients.

2. Official Description

The official description of CPT code 53240 is the surgical creation of a pouch or sac by oversewing a cyst or the neck of a diverticulum. This procedure causes the lining of the pouch to eventually separate from the membrane, and the defect fills in by granulation.

3. Procedure

1. The provider preps and anesthetizes the patient.
2. For female patients, the provider makes a small incision in the anterior vaginal wall to access the urethra. The incision is extended to the level of the fascia and muscle.
3. The provider identifies the urethral diverticulum and marsupializes it by raising the edges of the diverticulum and suturing them together to create a pouch.
4. The provider closes the urethral incision over a catheter placed in the urethra for better healing.
5. For male patients, the provider performs a urethroscopy and inserts a catheter through the urethra.
6. The provider ties off or sutures the neck of the diverticulum to close it.
7. Copious irrigation is performed, and the catheter is left in place to be removed at a later date.
8. The provider controls any bleeding and closes the incision in the vagina (for female patients) in layers using absorbable sutures.

4. Qualifying circumstances

CPT 53240 is applicable to both male and female patients with mid and distal urethral diverticula. The procedure is performed to improve urination and relieve pain. It is important to note that this code should not be used for other types of diverticula or for diverticula located in different areas of the body.

5. When to use CPT code 53240

CPT code 53240 should be used when a provider performs the marsupialization procedure for a urethral diverticulum in both male and female patients. It is important to ensure that the diverticulum is located in the mid or distal urethra and that the procedure is performed to improve urination and relieve pain.

6. Documentation requirements

To support a claim for CPT 53240, the provider must document the following information:

• Patient’s diagnosis of a urethral diverticulum
• Details of the procedure performed, including the incision, marsupialization, and closure
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53240, ensure that the procedure is performed for a urethral diverticulum in both male and female patients. It is important to follow the documentation requirements and provide accurate information on the claim. There are no specific guidelines regarding reporting CPT 53240 with other codes.

8. Historical information

CPT 53240 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 female patient undergoes marsupialization of a urethral diverticulum to improve urination and relieve pain.
2. A male patient with a urethral diverticulum undergoes the marsupialization procedure to alleviate symptoms.
3. A provider performs the marsupialization procedure on a female patient with a mid-urethral diverticulum.
4. A male patient with a distal urethral diverticulum undergoes the marsupialization procedure to address urinary issues.
5. A female patient with a complicated urethral diverticulum undergoes marsupialization to improve her quality of life.
6. A provider performs the marsupialization procedure on a male patient with a mid-urethral diverticulum to alleviate discomfort.
7. A female patient with a urethral diverticulum undergoes the marsupialization procedure to relieve pain and improve urinary flow.
8. A male patient with a distal urethral diverticulum undergoes marsupialization to address urinary retention.
9. A provider performs the marsupialization procedure on a female patient with a complicated urethral diverticulum to improve her symptoms.
10. A male patient with a mid-urethral diverticulum undergoes the marsupialization procedure to alleviate urinary discomfort.