How To Use CPT Code 53265

CPT 53265 describes the excision or fulguration of a urethral caruncle, a benign fleshy outgrowth, to improve urination and relieve pain in both male and female patients. 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 53265?

CPT 53265 is used to describe the excision or fulguration of a urethral caruncle, which is a benign fleshy outgrowth, in both male and female patients. This procedure is performed to improve urination and relieve pain. The provider may choose to excise the caruncle by removing it or use electrocautery to fulgurate it.

2. Official Description

The official description of CPT code 53265 is: ‘Excision or fulguration; urethral caruncle.’

3. Procedure

1. The provider prepares and anesthetizes the patient.
2. In the case of a female patient, the provider makes a small incision in the anterior vaginal wall to access the urethra.
3. The provider separates the urethra from the vaginal wall and identifies the urethral caruncle.
4. The caruncle is dissected off the urethra and removed, or it is fulgurated using electrocautery.
5. A catheter is typically inserted into the urethra to promote healing.
6. The provider controls any bleeding and closes the incision in layers.

4. Qualifying circumstances

CPT 53265 is performed on both male and female patients who have a urethral caruncle. The procedure is done to improve urination and relieve pain. The provider may choose to excise the caruncle or fulgurate it using electrocautery.

5. When to use CPT code 53265

CPT code 53265 should be used when the provider performs the excision or fulguration of a urethral caruncle in a male or female patient. This code should not be used for other procedures or conditions.

6. Documentation requirements

To support a claim for CPT 53265, the provider must document the following information:

• Patient’s diagnosis of a urethral caruncle
• Details of the procedure performed (excision or fulguration)
• Any additional procedures or techniques used
• Date of the procedure
• Start and end time of the procedure
• Any complications or adverse events
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53265, ensure that the procedure performed is the excision or fulguration of a urethral caruncle. Report this code only once per patient encounter. It is important to follow the specific documentation requirements for this code. Do not report CPT 53265 with other codes unless additional procedures or services were performed.

8. Historical information

CPT 53265 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 excision of a urethral caruncle to improve urination and relieve pain.
2. A male patient undergoes fulguration of a urethral caruncle using electrocautery to alleviate symptoms.
3. A provider performs excision of a urethral caruncle in a female patient to address urinary difficulties.
4. A male patient undergoes fulguration of a urethral caruncle to alleviate pain and improve urinary flow.
5. A female patient undergoes excision of a urethral caruncle to relieve discomfort and improve urination.
6. A provider performs fulguration of a urethral caruncle in a male patient to address urinary symptoms.
7. A female patient undergoes excision of a urethral caruncle to alleviate pain and improve urinary function.
8. A male patient undergoes fulguration of a urethral caruncle to relieve discomfort and improve urination.
9. A provider performs excision of a urethral caruncle in a female patient to address urinary difficulties.
10. A male patient undergoes fulguration of a urethral caruncle to alleviate pain and improve urinary flow.