How To Use CPT Code 53400

CPT 53400 describes the first stage of urethroplasty, which involves repairing a urethral defect or injury. 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 53400?

CPT 53400 is used to describe the first stage of urethroplasty, a surgical procedure that repairs a urethral defect or injury. During this stage, the healthcare provider identifies the defect, removes any obstructing tissue, and sutures the mucosal edges of the urethra to the skin.

2. Official Description

The official description of CPT code 53400 is: ‘Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type)’. This code specifically refers to the initial stage of the urethroplasty procedure, which involves repairing a urethral defect or injury.

3. Procedure

1. The healthcare provider begins by prepping and anesthetizing the patient.
2. Using a catheter or urethrography, the provider identifies the urethral defect and marks its location.
3. A transurethral suprapubic incision is made around the catheter, extending it to the level of the fascia and muscle.
4. An incision is made over the defect, and a skin flap is raised on the opposite side.
5. The skin flap is sutured with surrounding fascia and mucosa to repair the defect.
6. A catheter is typically left in the urethra to aid in healing.
7. The provider controls any bleeding and closes the suprapubic incision in layers.

4. Qualifying circumstances

CPT 53400 is used when a patient requires urethroplasty for a fistula, diverticulum, or stricture (such as Johannsen type). These conditions involve abnormal passageways, pouches, or narrowing in the urethra. The procedure is performed by a healthcare provider who is trained and qualified to perform urethroplasty.

5. When to use CPT code 53400

CPT code 53400 should be used when the healthcare provider performs the first stage of urethroplasty to repair a urethral defect or injury. It is important to note that this code specifically applies to the initial stage of the procedure and should not be used for subsequent stages or other types of urethroplasty.

6. Documentation requirements

To support a claim for CPT 53400, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the need for urethroplasty
• Details of the procedure, including the specific defect or injury being repaired
• Date of the procedure
• Start and end time of the procedure
• Any additional relevant information, such as the use of contrast material or specific techniques employed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53400, ensure that the procedure is performed by a qualified healthcare provider and that it meets the criteria for urethroplasty. It is important to follow the specific guidelines and documentation requirements set forth by the payer. Additionally, be aware of any bundling or unbundling issues and use appropriate modifiers if necessary.

8. Historical information

CPT 53400 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 healthcare provider performs the first stage of urethroplasty to repair a fistula in the urethra.
2. A patient undergoes the initial stage of urethroplasty to repair a diverticulum in the urethra.
3. A healthcare provider performs the first stage of urethroplasty to repair a stricture (Johannsen type) in the urethra.
4. A patient requires the first stage of urethroplasty to repair a complex urethral defect.
5. A healthcare provider performs the initial stage of urethroplasty to repair a traumatic injury to the urethra.
6. A patient undergoes the first stage of urethroplasty to repair a congenital urethral abnormality.
7. A healthcare provider performs the initial stage of urethroplasty to repair a recurrent urethral defect.
8. A patient requires the first stage of urethroplasty to repair a urethral defect caused by previous surgery.
9. A healthcare provider performs the first stage of urethroplasty to repair a urethral defect resulting from radiation therapy.
10. A patient undergoes the initial stage of urethroplasty to repair a urethral defect caused by a foreign body.