How To Use CPT Code 53600

CPT 53600 describes the dilation of a urethral stricture in male patients using a sound or urethral dilator. 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 53600?

CPT 53600 is used to describe the dilation of a urethral stricture in male patients. During this procedure, a healthcare provider gently inserts a dilator through the meatus to widen the stricture located towards the tip of the penis. The goal is to improve urinary flow and prevent infection. This code is specifically used for the initial visit of the patient for this treatment.

2. Official Description

The official description of CPT code 53600 is: ‘Dilation of urethral stricture by passage of sound or urethral dilator, male; initial.’

3. Procedure

1. The healthcare provider selects a sound or urethral dilator to dilate the urethral stricture.
2. Gently and carefully, the provider inserts the dilator through the meatus and advances it towards the tip of the penis.
3. The provider gradually increases the diameter of the dilator to widen the stricture and improve urinary flow.
4. The procedure aims to widen the urethral channel without causing additional scarring or tearing of the urethra.
5. This code is specifically used for the initial visit of the patient for this treatment.

4. Qualifying circumstances

CPT 53600 is used for male patients with a urethral stricture that requires dilation. The procedure is performed by a healthcare provider to improve urinary flow and prevent infection. It is important to note that this code is specifically used for the initial visit of the patient for this treatment.

5. When to use CPT code 53600

CPT code 53600 should be used when a healthcare provider performs the dilation of a urethral stricture in a male patient during the initial visit for this treatment. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 53600, the healthcare provider must document the following information:

• Patient’s diagnosis of a urethral stricture
• Procedure performed, including the use of a sound or urethral dilator
• Date of the initial visit
• Details of the procedure, including the insertion and advancement of the dilator
• Any complications or adverse events
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53600, ensure that the procedure is performed on a male patient and that it is the initial visit for this treatment. It is important to accurately document the procedure and meet the criteria outlined in the code description. Additionally, be aware of any specific guidelines or requirements from insurance providers or payers.

8. Historical information

CPT 53600 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider performs the dilation of a urethral stricture in a male patient during the initial visit for this treatment.
2. Using a sound or urethral dilator, the provider gently widens the stricture located towards the tip of the penis to improve urinary flow.
3. During the initial visit, a healthcare provider performs the dilation of a urethral stricture in a male patient using a sound or urethral dilator.
4. With the goal of improving urinary flow, the provider carefully inserts and advances the dilator through the meatus to widen the stricture.
5. A male patient with a urethral stricture undergoes the dilation procedure during the initial visit with a healthcare provider.
6. The provider selects a suitable dilator and performs the dilation of the urethral stricture in a male patient during the first visit for this treatment.
7. During the initial visit, a healthcare provider gently dilates the urethral stricture in a male patient using a sound or urethral dilator.
8. With precision and care, the provider widens the stricture located towards the tip of the penis to improve urinary flow.
9. A male patient seeks treatment for a urethral stricture and undergoes the dilation procedure during the initial visit with a healthcare provider.
10. The provider uses a sound or urethral dilator to gently dilate the stricture and improve urinary flow in a male patient during the first visit for this treatment.