How To Use CPT Code 53500

CPT 53500 describes a surgical procedure known as urethrolysis, which is performed to treat postoperative urethral obstruction in female patients. This article will provide an overview of CPT code 53500, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53500?

CPT 53500 is a code used to describe a surgical procedure called urethrolysis. This procedure is performed to treat postoperative urethral obstruction in female patients. It involves the excision of surrounding tissue from the urethra and the pubic bone to alleviate the obstruction caused by excessive scar tissue formation. It is important to note that CPT code 53500 should not be reported in conjunction with CPT code 52000.

2. Official Description

The official description of CPT code 53500 is: ‘Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring).’ It is important to remember that for urethrolysis by the retropubic approach, CPT code 53899 should be used instead.

3. Procedure

1. The provider begins by making a midline U-shaped incision in the anterior vaginal wall under endoscopic guidance.
2. They then visualize the fibrous bands and periurethral scar tissue that adhere the urethra to the pubic bone and carefully dissect them.
3. After dissecting the scar tissue bilaterally, the provider proceeds with sharp dissection to reach the retropubic space.
4. They mobilize the urethra from the surrounding fibrous tissue until traction on the catheter causes some posterior urethral rotation into the vagina.
5. The provider ensures any bleeding is controlled, closes the incision in layers, and removes the Foley catheter before the patient is discharged.
6. Cystourethroscopy is performed to assess tissue damage or identify the source of the problem and to examine the urethra after the procedure.

4. Qualifying circumstances

CPT code 53500 is used when a female patient experiences postoperative urethral obstruction due to prior anti-incontinence surgeries and the formation of excessive scar tissue. The procedure is performed by a provider to alleviate the obstruction and improve urinary flow. It is important to note that CPT code 53500 should not be reported in conjunction with CPT code 52000.

5. When to use CPT code 53500

CPT code 53500 should be used when a female patient requires urethrolysis to treat postoperative urethral obstruction caused by excessive scar tissue. It is important to ensure that the procedure is performed transvaginally and includes cystourethroscopy. CPT code 53500 should not be reported in conjunction with CPT code 52000.

6. Documentation requirements

To support a claim for CPT code 53500, the provider must document the following information:

• Patient’s diagnosis of postoperative urethral obstruction
• Details of the surgical procedure performed, including the incision, dissection of scar tissue, mobilization of the urethra, and closure of the incision
• Date of the procedure
• Use of cystourethroscopy during the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 53500, ensure that the procedure is performed transvaginally and includes cystourethroscopy. It is important to note that CPT code 53500 should not be reported in conjunction with CPT code 52000. Pay attention to any specific guidelines provided by the payer regarding documentation and coding for this procedure.

8. Historical information

CPT code 53500 was added to the Current Procedural Terminology system on January 1, 2004. There have been no updates or changes to the code since its addition.

9. Examples

1. A female patient undergoes urethrolysis to treat postoperative urethral obstruction caused by excessive scar tissue following anti-incontinence surgery.
2. A provider performs urethrolysis on a patient who experiences urinary flow obstruction due to the formation of fibrous bands and periurethral scar tissue.
3. Urethrolysis is performed on a female patient to alleviate postoperative urethral obstruction and improve urinary function.
4. A provider performs transvaginal urethrolysis with cystourethroscopy to treat a patient with postoperative urethral obstruction.
5. A female patient undergoes urethrolysis to relieve urinary flow obstruction caused by scar tissue formation following prior surgeries.
6. Urethrolysis is performed on a patient with postoperative urethral obstruction to restore normal urinary function.
7. A provider performs transvaginal urethrolysis with cystourethroscopy to alleviate urinary flow obstruction in a female patient.
8. A female patient undergoes urethrolysis to treat postoperative urethral obstruction caused by excessive scar tissue formation.
9. Urethrolysis is performed on a patient with prior anti-incontinence surgeries to alleviate urinary flow obstruction.
10. A provider performs transvaginal urethrolysis with cystourethroscopy to treat a female patient with postoperative urethral obstruction.