How To Use CPT Code 53446

CPT 53446 describes the removal of an inflatable urethral/bladder neck sphincter, including the pump, reservoir, and cuff. 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 53446?

CPT 53446 is used to describe the removal of an inflatable artificial urinary sphincter. This procedure is performed when the device fails to stop incontinence in a patient or in cases of infection or erosion of the system. The provider removes the entire system, including the pump, reservoir, and cuff.

2. Official Description

The official description of CPT code 53446 is: ‘Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made at the suprapubic region, reopening the previous incision site.
3. The provider identifies the artificial cuff system by dissecting the overlying tissues.
4. The device is carefully removed.
5. The site is sutured to close it.
6. Any bleeding is controlled, and the incision is closed in layers.

4. Qualifying circumstances

CPT 53446 is performed when the inflatable artificial urinary sphincter fails to stop incontinence in a patient or in cases of infection or erosion of the system. It is important to note that this procedure is only performed when necessary and after other treatment options have been exhausted.

5. When to use CPT code 53446

CPT code 53446 should be used when the provider performs the complete removal of an inflatable artificial urinary sphincter, including the pump, reservoir, and cuff. It is important to ensure that this procedure is medically necessary and meets the criteria for reimbursement.

6. Documentation requirements

To support a claim for CPT 53446, the provider must document the following information:

• Reason for the removal of the inflatable artificial urinary sphincter
• Details of the procedure, including the incision site and closure method
• Any complications encountered during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53446, ensure that the procedure meets the necessary criteria for reimbursement. It is important to append modifier 52, Reduced services, if only the cuff of the artificial urinary sphincter is removed. Additionally, be aware of any specific guidelines or requirements from the payer regarding documentation or coding for this procedure.

8. Historical information

CPT 53446 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 an inflatable artificial urinary sphincter undergoes a removal procedure due to infection.
2. A provider performs the removal of an inflatable artificial urinary sphincter in a patient who experienced erosion of the system.
3. After the failure of an inflatable artificial urinary sphincter to stop incontinence, a patient undergoes a complete removal procedure.
4. A provider removes an inflatable artificial urinary sphincter, including the pump, reservoir, and cuff, in a patient who experienced complications with the device.
5. A patient with an inflatable artificial urinary sphincter undergoes a removal procedure due to the device’s failure to effectively manage incontinence.
6. After careful consideration and evaluation, a provider decides to remove an inflatable artificial urinary sphincter in a patient due to infection.
7. A patient with an inflatable artificial urinary sphincter undergoes a complete removal procedure after experiencing erosion of the system.
8. A provider performs the removal of an inflatable artificial urinary sphincter in a patient who experienced complications with the device.
9. Due to the failure of an inflatable artificial urinary sphincter to stop incontinence, a patient undergoes a complete removal procedure.
10. A patient with an inflatable artificial urinary sphincter undergoes a removal procedure due to the device’s inability to effectively manage incontinence.