How To Use CPT Code 53405

CPT 53405 describes the second stage of urethroplasty, which involves the formation of a new urethral structure and urinary diversion. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53405?

CPT 53405 is used to describe the second stage of urethroplasty, specifically the formation of a new urethral structure and urinary diversion. This procedure is performed to repair a urethral defect or injury and maintain a normal passageway for urine.

2. Official Description

The official description of CPT code 53405 is: ‘Urethroplasty; second stage (formation of urethra), including urinary diversion.’

3. Procedure

1. After appropriate prepping and anesthesia, the provider reopens the suprapubic incision from the first stage of the repair.
2. The previously created urethral flap is identified and used to form a new urethral passage.
3. The provider raises both skin flaps and sutures them end to end in a tubular manner, aligning with the urethra.
4. Bleeding is controlled, a Foley catheter is placed in the bladder for urine flow diversion, and the suprapubic incision is closed in layers.

4. Qualifying circumstances

CPT 53405 is performed on patients who require repair of a urethral defect or injury. It is important to note that this code specifically refers to the second stage of urethroplasty, which involves the formation of a new urethral structure and urinary diversion.

5. When to use CPT code 53405

CPT code 53405 should be used when the provider is performing the second stage of urethroplasty, which includes the formation of a new urethral structure and urinary diversion. It is important to ensure that the procedure aligns with the official description of the code.

6. Documentation requirements

To support a claim for CPT 53405, the provider must document the following information:

• Details of the patient’s condition and the need for urethroplasty
• Specific steps taken during the procedure, including the formation of the new urethral structure and urinary diversion
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 53405, ensure that the procedure aligns with the official description and that all necessary documentation is provided. It is important to follow any specific guidelines or requirements set by the payer. Additionally, consider any applicable modifiers or additional codes that may need to be reported in conjunction with CPT 53405.

8. Historical information

CPT 53405 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 patient undergoes the second stage of urethroplasty, during which the provider forms a new urethral structure and performs urinary diversion.
2. After the initial repair, the patient requires the second stage of urethroplasty to create a new urethral passage and divert urine flow.
3. A provider performs the second stage of urethroplasty, including the formation of a new urethral structure and urinary diversion, for a patient with a urethral defect.
4. During the second stage of urethroplasty, the provider reconstructs the urethra and diverts urine flow using a specific technique.
5. A patient undergoes the second stage of urethroplasty, which involves the formation of a new urethral structure and urinary diversion to address a previous injury.
6. After the initial repair, the patient requires the second stage of urethroplasty to create a functional urethral passage and divert urine flow.
7. A provider performs the second stage of urethroplasty, including the formation of a new urethral structure and urinary diversion, for a patient with a complex urethral defect.
8. During the second stage of urethroplasty, the provider reconstructs the urethra and diverts urine flow using advanced surgical techniques.
9. A patient undergoes the second stage of urethroplasty, which involves the formation of a new urethral structure and urinary diversion to address a congenital abnormality.
10. After the initial repair, the patient requires the second stage of urethroplasty to create a functional urethral passage and divert urine flow due to a previous surgery.