How To Use CPT Code 53451

CPT 53451 describes the insertion of a periurethral transperineal adjustable balloon continence device, including cystourethroscopy and imaging guidance. 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 53451?

CPT 53451 is used to describe the insertion of a periurethral transperineal adjustable balloon continence device. This procedure involves the placement of an adjustable balloon on each side of the urethra to treat incontinence. It includes cystourethroscopy and imaging guidance to ensure accurate placement of the device.

2. Official Description

The official description of CPT code 53451 is: ‘Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance.’

3. Procedure

1. The provider performs cystourethroscopy to visualize and palpate the urethra.
2. Incisions are made in the perineum, between the anus and external genitalia.
3. The provider dissects through perineal tissues and inserts a sheath towards the bladder neck under imaging guidance.
4. Tissue dilation may be performed to ensure space for the balloon.
5. The appropriate size balloon is selected, inflated with solution, and inserted through the sheath.
6. The provider confirms the position and inflation of the balloon using imaging.
7. The same procedure is performed on the opposite side, and urethral closure is confirmed.
8. Pockets are created, and ports for the balloons are placed under the skin.
9. The incisions are closed, and a catheter may be inserted if necessary.

4. Qualifying circumstances

CPT 53451 is performed on patients with incontinence who require the insertion of a periurethral transperineal adjustable balloon continence device. The procedure is done under cystourethroscopic and imaging guidance to ensure accurate placement of the device. It should not be reported in conjunction with codes 52000, 53452, 53453, 53454, or 76000.

5. When to use CPT code 53451

CPT code 53451 should be used when a provider performs the bilateral insertion of a periurethral transperineal adjustable balloon continence device, including cystourethroscopy and imaging guidance. It is appropriate for patients with incontinence who require this specific procedure.

6. Documentation requirements

To support a claim for CPT 53451, the provider must document the following information:

• Patient’s diagnosis of incontinence and the need for the periurethral transperineal adjustable balloon continence device
• Details of the cystourethroscopy and imaging guidance performed
• Date of the procedure
• Specific steps taken during the procedure, including incisions, balloon insertion, and confirmation of position and inflation
• Confirmation of urethral closure and placement of ports for the balloons
• Details of any additional procedures performed, such as catheter insertion
• Provider’s signature

7. Billing guidelines

When billing for CPT 53451, ensure that the procedure includes bilateral insertion of the periurethral transperineal adjustable balloon continence device, cystourethroscopy, and imaging guidance. Do not report CPT 53451 in conjunction with codes 52000, 53452, 53453, 53454, or 76000. Review the descriptors of similar codes to ensure proper code choice.

8. Historical information

CPT 53451 was added to the Current Procedural Terminology system on January 1, 2022. There have been no updates to the code since its addition.

9. Examples

1. A patient with incontinence undergoes the bilateral insertion of a periurethral transperineal adjustable balloon continence device, including cystourethroscopy and imaging guidance.
2. A provider performs the procedure on a patient with stress urinary incontinence to improve bladder control.
3. A patient with post-prostatectomy incontinence receives the bilateral insertion of the device to manage their symptoms.
4. A provider performs the procedure on a patient with neurogenic bladder dysfunction to improve urinary control.
5. A patient with mixed urinary incontinence undergoes the bilateral insertion of the device to address their condition.
6. A provider performs the procedure on a patient with overflow incontinence to help manage their symptoms.
7. A patient with urge incontinence receives the bilateral insertion of the device to improve bladder control.
8. A provider performs the procedure on a patient with functional incontinence to address their urinary control issues.
9. A patient with postpartum incontinence undergoes the bilateral insertion of the device to manage their symptoms.
10. A provider performs the procedure on a patient with urinary incontinence due to pelvic organ prolapse to improve bladder control.