How To Use CPT Code 53452

CPT 53452 describes the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum. 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 53452?

CPT 53452 is used to describe the placement of an adjustable balloon continence device on one side of the urethra. This procedure is performed using a minimally invasive approach through the perineum, which is the area between the anus and external genitalia. The device is used to treat incontinence, which is the lack of control over urine or feces.

2. Official Description

The official description of CPT code 53452 is: ‘Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance.’ It is important to note that CPT code 53452 should not be reported in conjunction with codes 52000, 53451, 53453, 53454, or 76000.

3. Procedure

1. When performing CPT 53452, the provider begins by preparing and anesthetizing the patient.
2. The provider then performs cystourethroscopy, which involves inserting a flexible or rigid tube with a camera into the urethra to examine the urethra and urinary tract.
3. After draining the bladder, the provider leaves the cystourethroscope in place to visualize and palpate the urethra.
4. An incision is made in the perineum, and the provider dissects through the perineal tissues to create enough space for the insertion of a sheath.
5. The provider advances the sheath toward the bladder neck under imaging guidance.
6. If necessary, the provider dilates the tissue on either side of the urethral opening at the bladder neck using a tissue expander.
7. The appropriate size of the balloon is determined, and it is inflated with a solution, ensuring the removal of air bubbles.
8. The balloon is inserted through the sheath, and the provider confirms its proper position using imaging.
9. The provider inflates the balloon with more solution and confirms its position and inflation using imaging.
10. The provider ensures the integrity of the urethra using cystourethroscopy.
11. A pocket is created, and the port for the balloon is placed under the skin.
12. The incision is closed, and a catheter may be inserted if necessary until the patient is able to void.

4. Qualifying circumstances

CPT 53452 is performed on patients who require the placement of an adjustable balloon continence device to treat incontinence. The procedure is indicated for individuals who have a lack of control over urine or feces. It is important to note that CPT 53452 should not be reported in conjunction with codes 52000, 53451, 53453, 53454, or 76000.

5. When to use CPT code 53452

CPT code 53452 should be used when a provider performs the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum. It is important to note that CPT 53452 should not be reported in conjunction with codes 52000, 53451, 53453, 53454, or 76000.

6. Documentation requirements

To support a claim for CPT 53452, the provider must document the following information:

• Patient’s diagnosis indicating the need for the placement of an adjustable balloon continence device
• Details of the procedure, including cystourethroscopy and imaging guidance
• Date of the procedure
• Start and end time of the procedure
• Confirmation of the proper position and inflation of the balloon using imaging
• Confirmation of urethral closure by the balloons
• Details of any additional procedures performed, such as the creation of a pocket and placement of the port
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53452, it is important to ensure that the procedure is performed by a qualified provider and that the documentation supports the medical necessity of the procedure. CPT 53452 should not be reported in conjunction with codes 52000, 53451, 53453, 53454, or 76000. It is important to review the descriptors of similar codes to ensure proper code selection. Additional tips for reporting CPT 53452 may be available from coding resources.

8. Historical information

CPT 53452 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 provider performs the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum to treat incontinence.
2. A patient with urinary incontinence undergoes the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum.
3. A provider performs the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum for a patient with fecal incontinence.
4. An individual with urinary incontinence undergoes the placement of an adjustable balloon continence device on one side of the urethra using a minimally invasive approach through the perineum.