How To Use CPT Code 53449

CPT 53449 describes the repair 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 53449?

CPT 53449 is used to describe the repair of a previously implanted artificial urinary sphincter due to complications such as tissue atrophy or cuff erosion. The procedure involves reopening the incision in the suprapubic area, evaluating the artificial sphincter, and making necessary adjustments or repairs. The provider then reapproximates the overlying tissues, controls any bleeding, and closes the incision with sutures.

2. Official Description

The official description of CPT code 53449 is: ‘Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider reopens the incision in the suprapubic area and evaluates the artificial sphincter.
3. If there is tissue atrophy, the provider adjusts the balloon pressure or changes the cuff site to an area with better tissue integrity.
4. If there is cuff erosion, the provider repairs the affected parts.
5. The provider reapproximates the overlying tissues, controls any bleeding, and closes the incision with sutures.

4. Qualifying circumstances

CPT 53449 is performed on patients who have previously had an artificial urinary sphincter implanted and are experiencing complications such as tissue atrophy or cuff erosion. The procedure is done to address these specific issues and improve the function of the sphincter. It is important to note that this code is only applicable to repairs and not removal and replacement procedures.

5. When to use CPT code 53449

CPT code 53449 should be used when a provider is performing a repair of an inflatable urethral/bladder neck sphincter, including the pump, reservoir, and cuff. It is important to ensure that the procedure is being done to address complications such as tissue atrophy or cuff erosion. If the provider is removing and replacing the entire device, a different code should be used.

6. Documentation requirements

To support a claim for CPT 53449, the provider must document the following information:

• Reason for the repair (e.g., tissue atrophy, cuff erosion)
• Details of the repair procedure performed
• Date of the procedure
• Any additional procedures performed during the same operative session, if applicable
• Signature of the provider

7. Billing guidelines

When billing for CPT 53449, ensure that the procedure performed aligns with the description of the code. It is important to note that CPT 53449 should not be reported with other codes for removal and replacement procedures or procedures performed through an infected field. Additional tips for reporting CPT 53449 include performing cystoscopy during the procedure, using code 52000 for cystourethroscopy, and using code 53447 for removal and replacement procedures.

8. Historical information

CPT 53449 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 a repair of their inflatable urethral/bladder neck sphincter due to tissue atrophy.
2. A provider performs a repair of an artificial urinary sphincter to address cuff erosion.
3. During a procedure, the provider adjusts the balloon pressure of the artificial sphincter to improve its function.
4. A patient undergoes a repair of their artificial urinary sphincter to address complications.
5. A provider repairs a previously implanted artificial urinary sphincter to improve its effectiveness.
6. Another example of a patient undergoing a repair of their inflatable urethral/bladder neck sphincter due to complications.
7. A provider performs a repair of an artificial urinary sphincter to address issues with tissue atrophy.
8. During the procedure, the provider makes necessary repairs to the cuff of the artificial sphincter.
9. A patient undergoes a repair of their artificial urinary sphincter to improve their urinary continence.
10. A provider performs a repair of an inflatable urethral/bladder neck sphincter to address complications from the previous implantation.