How To Use CPT Code 53601

CPT 53601 describes the dilation of a urethral stricture in male patients by the passage of a sound or urethral dilator. 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 53601?

CPT 53601 is used to describe the dilation of a urethral stricture in male patients. This procedure involves the insertion of a sound or urethral dilator to widen the narrowing in the urethra, improving urinary flow and preventing infection. It is important to note that this code is specifically for subsequent visits of the patient, not the initial visit.

2. Official Description

The official description of CPT code 53601 is: ‘Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent.’

3. Procedure

1. The healthcare provider gently inserts a sound or urethral dilator through the meatus, which is the urethral opening, to dilate the urethral stricture.
2. The dilator is gradually increased in diameter to widen the narrowing in the urethra without causing additional scarring or tearing.
3. This procedure is performed during subsequent visits of the patient when the symptoms of the stricture recur.

4. Qualifying circumstances

CPT 53601 is used for male patients who have a recurring 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 for subsequent visits, not the initial visit.

5. When to use CPT code 53601

CPT code 53601 should be used when a male patient with a urethral stricture requires dilation during subsequent visits. It is important to use this code only for subsequent visits and not for the initial visit. If the provider dilates the stricture by passing a filiform or follower, a different code should be used.

6. Documentation requirements

To support a claim for CPT 53601, the healthcare provider must document the following information:

• Identification of the patient’s recurring urethral stricture
• Description of the sound or urethral dilator used
• Date of the procedure
• Details of the dilation procedure, including the gradual increase in diameter
• Any complications or adverse events
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53601, ensure that the procedure is performed on a male patient and is a subsequent visit for the dilation of a urethral stricture. It is important to use the appropriate code for the initial visit (53600) or if the provider dilates the stricture using a filiform and follower (53621). Take note of any specific guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 53601 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 urologist performs the dilation of a urethral stricture in a male patient during a subsequent visit.
2. A patient with a recurring urethral stricture undergoes dilation by a healthcare provider to improve urinary flow.
3. A male patient presents with symptoms of a urethral stricture, and the healthcare provider performs dilation during a subsequent visit.
4. A urologist uses a sound dilator to widen the narrowing in the urethra of a male patient with a recurring stricture.
5. A healthcare provider performs the dilation of a urethral stricture in a male patient to prevent infection and improve urinary flow.
6. A patient with a recurring urethral stricture undergoes dilation during a subsequent visit to relieve symptoms.
7. A urologist gently inserts a urethral dilator to widen the narrowing in the urethra of a male patient during a subsequent visit.
8. A male patient with a recurring urethral stricture undergoes dilation to improve urinary flow and prevent complications.
9. A healthcare provider performs the dilation of a urethral stricture in a male patient to alleviate symptoms and improve quality of life.
10. A urologist uses a sound dilator to dilate the urethral stricture in a male patient during a subsequent visit.