How To Use CPT Code 53453

CPT 53453 describes the removal of a periurethral transperineal adjustable balloon continence device. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53453?

CPT 53453 is used to describe the removal of a periurethral transperineal adjustable balloon continence device. This code is used when a healthcare provider removes a previously placed balloon continence device using a minimally invasive transperineal approach.

2. Official Description

The official description of CPT code 53453 is: ‘Periurethral transperineal adjustable balloon continence device; removal, each balloon. Do not report 53453 in conjunction with 53451, 53452, 53454.’

3. Procedure

1. When the patient is appropriately prepped and anesthetized, the healthcare provider opens the incision made for balloon insertion in the perineum.
2. The healthcare provider grasps the tube leading from the balloon and gently pulls the tube, balloon, and port out.
3. The healthcare provider then closes the incision.
4. CPT code 53453 should be reported for each balloon removed.

4. Qualifying circumstances

Patients who have previously had a periurethral transperineal adjustable balloon continence device placed and now require its removal are eligible for CPT 53453. This procedure is performed by a healthcare provider using a minimally invasive transperineal approach.

5. When to use CPT code 53453

CPT code 53453 should be used when a healthcare provider performs the removal of a periurethral transperineal adjustable balloon continence device. It should not be reported in conjunction with CPT codes 53451, 53452, or 53454.

6. Documentation requirements

To support a claim for CPT 53453, the healthcare provider must document the following information:

• Confirmation of the previous placement of the balloon continence device
• Date of the removal procedure
• Details of the procedure, including the incision site and the method used to remove the balloon
• Number of balloons removed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53453, ensure that the procedure involves the removal of a periurethral transperineal adjustable balloon continence device. Do not report this code in conjunction with CPT codes 53451, 53452, or 53454.

8. Historical information

CPT 53453 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 healthcare provider removes a periurethral transperineal adjustable balloon continence device from a patient who had previously undergone the placement procedure.
2. A patient undergoes the removal of a balloon continence device using a minimally invasive transperineal approach performed by a healthcare provider.
3. A healthcare provider performs the removal of a periurethral transperineal adjustable balloon continence device on a patient who no longer requires its use.
4. A patient who had a balloon continence device placed previously has the device removed by a healthcare provider using a minimally invasive transperineal approach.
5. A healthcare provider removes a periurethral transperineal adjustable balloon continence device from a patient who experienced complications related to its use.
6. A patient undergoes the removal of a balloon continence device performed by a healthcare provider to address issues with its functionality.
7. A healthcare provider performs the removal of a periurethral transperineal adjustable balloon continence device on a patient who wishes to discontinue its use.
8. A patient who had a balloon continence device placed previously has the device removed by a healthcare provider due to the patient’s preference.
9. A healthcare provider removes a periurethral transperineal adjustable balloon continence device from a patient who developed an infection related to its use.
10. A patient undergoes the removal of a balloon continence device performed by a healthcare provider to address discomfort and pain associated with its presence.