How To Use CPT Code 53440

CPT 53440 describes a sling operation that is performed to correct male urinary incontinence. This article will provide an overview of the code, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 53440?

CPT 53440 is used to describe a sling operation that is performed to correct male urinary incontinence. This procedure involves the insertion of a synthetic mesh sling or the creation of a sling using fascia to support the urethra and restore continence in male patients.

2. Official Description

The official description of CPT code 53440 is: ‘Sling operation for correction of male urinary incontinence (eg, fascia or synthetic).’ This code specifically refers to the surgical procedure performed to correct male urinary incontinence by inserting a sling made of fascia or synthetic material.

3. Procedure

1. The provider begins by making an incision in the perineum, which is the area between the anus and scrotum in males.
2. Next, the provider advances a sling made of fascia or synthetic material and fastens it to the muscles surrounding the urethra.
3. In some cases, the provider may insert titanium bone screws into the pubic bone and pass the sling through sutures attached to these screws to adjust the tension.
4. The provider then inserts a catheter and fills the bladder to check for any leakage.
5. After confirming the success of the procedure, the provider drains the bladder and controls any bleeding before closing the incision in layers.
6. A catheter is left in place for 24 hours, and after its removal, most men experience improved urinary control.

4. Qualifying circumstances

CPT 53440 is performed on male patients who are experiencing urinary incontinence and require surgical intervention to correct the condition. The procedure involves the use of a sling made of fascia or synthetic material to support the urethra and restore continence. It is important to note that this code is specific to male urinary incontinence correction and should not be used for other types of sling operations.

5. When to use CPT code 53440

CPT code 53440 should be used when a provider performs a sling operation to correct male urinary incontinence using fascia or synthetic material. It is important to ensure that the procedure aligns with the official description of the code and that the patient meets the qualifying circumstances for this specific procedure.

6. Documentation requirements

To support a claim for CPT code 53440, the provider must document the following information:

• Patient’s diagnosis of male urinary incontinence
• Details of the sling operation performed, including the type of sling material used (fascia or synthetic)
• Date of the procedure
• Specific steps involved in the procedure, such as the incision, sling insertion, and closure
• Confirmation of successful sling placement and absence of leakage
• Details of any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 53440, it is important to ensure that the procedure performed aligns with the official description of the code. This code should not be reported with other codes unless additional procedures, such as the placement of an artificial urinary sphincter, are performed. It is recommended to review the specific billing guidelines provided by the payer to ensure accurate reporting and reimbursement for the procedure.

8. Historical information

CPT code 53440 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a historical change on January 1, 2003, when the description was updated to specify the use of fascia or synthetic material for the sling operation.

9. Examples

1. A urologist performs a sling operation using synthetic material to correct urinary incontinence in a male patient.
2. A surgeon inserts a fascia sling to restore continence in a male patient experiencing urinary incontinence.
3. A urogynecologist performs a sling operation using synthetic material to correct urinary incontinence in a male patient.
4. A urological surgeon performs a sling operation using fascia material to restore continence in a male patient.
5. A urologist performs a sling operation using synthetic material to correct urinary incontinence in a male patient.
6. A surgeon inserts a fascia sling to restore continence in a male patient experiencing urinary incontinence.
7. A urogynecologist performs a sling operation using synthetic material to correct urinary incontinence in a male patient.
8. A urological surgeon performs a sling operation using fascia material to restore continence in a male patient.
9. A urologist performs a sling operation using synthetic material to correct urinary incontinence in a male patient.
10. A surgeon inserts a fascia sling to restore continence in a male patient experiencing urinary incontinence.