How To Use CPT Code 53454

CPT 53454 describes the percutaneous adjustment of fluid volume in 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 53454?

CPT 53454 can be used to describe the percutaneous adjustment of fluid volume in a periurethral transperineal adjustable balloon continence device. This code is used when a healthcare provider uses a needle to add or withdraw fluid from one or more balloons that are part of a continence device placed near the urethra. The adjustment is done to optimize the volume of the balloon(s) for effective continence management.

2. Official Description

The official description of CPT code 53454 is: ‘Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume. Do not report 53454 in conjunction with 53451, 53452, 53453. Report 53454 only once per patient encounter.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. A needle is inserted through the skin into the previously placed balloon port, which is located near the urethra.
3. The provider adjusts the fluid volume of the balloon(s) by adding or withdrawing fluid.
4. The adjustment is made to optimize the volume of the balloon(s) for effective continence management.
5. The needle is removed, and the provider checks for any bleeding.

4. Qualifying circumstances

CPT 53454 is used for patients who have a periurethral transperineal adjustable balloon continence device in place and require percutaneous adjustment of the balloon(s) fluid volume. This procedure is performed to optimize the volume of the balloon(s) for effective continence management. It is important to note that CPT 53454 should not be reported in conjunction with codes 53451, 53452, or 53453, and it should only be reported once per patient encounter.

5. When to use CPT code 53454

CPT code 53454 should be used when a healthcare provider performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device. This code should not be used in conjunction with codes 53451, 53452, or 53453, as they represent different services related to adjustable balloon continence devices. It is important to report CPT 53454 only once per patient encounter.

6. Documentation requirements

To support a claim for CPT 53454, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for percutaneous adjustment of the balloon(s) fluid volume
• Date of the procedure
• Details of the adjustment made, including the volume of fluid added or withdrawn
• Any complications or adverse events encountered during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53454, ensure that the procedure meets the criteria for this code, including the percutaneous adjustment of the balloon(s) fluid volume in a periurethral transperineal adjustable balloon continence device. It is important not to report CPT 53454 in conjunction with codes 53451, 53452, or 53453. Additionally, CPT 53454 should only be reported once per patient encounter.

8. Historical information

CPT 53454 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 performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device for a patient with stress urinary incontinence.
2. A patient with urge urinary incontinence undergoes a percutaneous adjustment of the fluid volume in their periurethral transperineal adjustable balloon continence device.
3. A healthcare provider performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device for a patient with mixed urinary incontinence.
4. A patient with overflow urinary incontinence undergoes a percutaneous adjustment of the fluid volume in their periurethral transperineal adjustable balloon continence device.
5. A healthcare provider performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device for a patient with functional urinary incontinence.
6. A patient with post-prostatectomy incontinence undergoes a percutaneous adjustment of the fluid volume in their periurethral transperineal adjustable balloon continence device.
7. A healthcare provider performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device for a patient with neurogenic urinary incontinence.
8. A patient with congenital urinary incontinence undergoes a percutaneous adjustment of the fluid volume in their periurethral transperineal adjustable balloon continence device.
9. A healthcare provider performs a percutaneous adjustment of the fluid volume in a periurethral transperineal adjustable balloon continence device for a patient with postpartum urinary incontinence.
10. A patient with traumatic urinary incontinence undergoes a percutaneous adjustment of the fluid volume in their periurethral transperineal adjustable balloon continence device.