How To Use CPT Code 53444

CPT 53444 describes the insertion of a dual cuff in patients with urinary incontinence, even after the insertion of an artificial urinary sphincter or in cases of high-grade stress incontinence. 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 53444?

CPT 53444 is used to describe the insertion of a dual cuff in patients with urinary incontinence. This procedure is performed when other interventions, such as the insertion of an artificial urinary sphincter, have not been successful or in cases of high-grade stress incontinence. The dual cuff is inserted to help control the flow of urine and improve continence.

2. Official Description

The official description of CPT code 53444 is the “Insertion of tandem cuff (dual cuff).” This code is used when the provider inserts a dual cuff in patients with urinary incontinence, even after the insertion of an artificial urinary sphincter, or in cases of high-grade stress incontinence.

3. Procedure

1. The provider begins by making a perineal incision below the scrotum.
2. They then dissect the Colles fascia and bulbocavernosus muscle off the bulbar urethra.
3. A clamp is passed behind the urethra to facilitate the procedure.
4. The provider measures the size of the bulbar urethra using a measuring tape to determine the appropriate size of the cuff.
5. The tandem cuff is tied around the urethra, and the tubing from the cuff is passed to the suprapubic wound after connecting it to the control pump.
6. Any bleeding is controlled, and the incision in the Colles fascia and the skin is closed in layers.

4. Qualifying circumstances

CPT 53444 is performed in patients with urinary incontinence who have not responded to other interventions, such as the insertion of an artificial urinary sphincter. It is also used in cases of high-grade stress incontinence. The procedure involves the insertion of a dual cuff to help control the flow of urine and improve continence.

5. When to use CPT code 53444

CPT code 53444 should be used when the provider performs the insertion of a dual cuff in patients with urinary incontinence, even after the insertion of an artificial urinary sphincter, or in cases of high-grade stress incontinence. It is important to ensure that the patient meets the qualifying circumstances for this procedure before using this code.

6. Documentation requirements

To support a claim for CPT 53444, the provider must document the following information:

• Patient’s diagnosis of urinary incontinence
• Reason for the insertion of a dual cuff
• Details of the procedure, including the size of the cuff and any complications encountered
• Date of the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53444, ensure that the procedure meets the qualifying circumstances described above. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement. Additionally, be aware of any bundling or unbundling rules that may apply to this code.

8. Historical information

CPT 53444 was added to the Current Procedural Terminology system on January 1, 2002. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with urinary incontinence undergoes the insertion of a dual cuff to improve continence.
2. A provider performs the insertion of a dual cuff in a patient with high-grade stress incontinence.
3. A patient who has previously had an artificial urinary sphincter inserted undergoes the insertion of a dual cuff to further improve continence.
4. A provider performs the insertion of a dual cuff in a patient who has not responded to other interventions for urinary incontinence.
5. A patient with urinary incontinence undergoes the insertion of a dual cuff after other treatment options have been exhausted.