How To Use CPT Code 53605

CPT 53605 describes the dilation of a urethral stricture or vesical neck in male patients using a sound or urethral dilator under general or spinal anesthesia. 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 53605?

CPT 53605 is used to describe the dilation of a urethral stricture or vesical neck in male patients. This procedure involves the use of a sound or urethral dilator to gradually widen the narrowed stricture. It is performed under general or spinal anesthesia to improve urinary flow and prevent infection.

2. Official Description

The official description of CPT code 53605 is the dilation of a urethral stricture or vesical neck by the passage of a sound or urethral dilator in male patients, under general or conduction (spinal) anesthesia. It is important to note that for dilation of a urethral stricture performed under local anesthesia, different CPT codes should be used (53600, 53601, 53620, 53621).

3. Procedure

1. The provider prepares and anesthetizes the patient with either general or spinal anesthesia.
2. Using a sound or urethral dilator, the provider gently inserts the instrument through the meatus and up through the urethra.
3. The provider gradually increases the diameter of the dilator to widen the narrowed stricture.
4. If the bladder neck is narrowed, the provider also dilates it.
5. The provider takes care to avoid scarring or tearing of the urethra during the procedure.

4. Qualifying circumstances

CPT 53605 is performed on male patients with a urethral stricture or vesical neck narrowing. The procedure is indicated to improve urinary flow and prevent infection. It is important to note that this code is specifically for procedures performed under general or spinal anesthesia. If the procedure is performed under local anesthesia, different CPT codes should be used.

5. When to use CPT code 53605

CPT code 53605 should be used when a provider performs the dilation of a urethral stricture or vesical neck in a male patient under general or spinal anesthesia. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 53605, the provider must document the following information:

• Patient’s diagnosis of urethral stricture or vesical neck narrowing
• Type of anesthesia used (general or spinal)
• Date of the procedure
• Details of the procedure, including the use of a sound or urethral dilator
• Any complications or adverse events
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53605, ensure that the procedure meets the specific criteria outlined in the code description. It is important to use the appropriate anesthesia modifier (e.g., modifier 23 for general anesthesia) to indicate the type of anesthesia used. Additionally, be aware of any bundling or unbundling issues and follow the guidelines provided by the payer.

8. Historical information

CPT 53605 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 under general anesthesia to improve urinary flow.
2. A patient with a vesical neck narrowing undergoes dilation of the bladder neck by a urologist using a sound or urethral dilator under spinal anesthesia.
3. A male patient with recurrent urinary tract infections undergoes dilation of a urethral stricture by a urologist to prevent further infections.
4. A urologist performs the dilation of a urethral stricture in a male patient with urinary retention under general anesthesia to relieve the obstruction.
5. A patient with a history of urethral trauma undergoes dilation of a urethral stricture by a urologist under spinal anesthesia to restore normal urinary function.
6. A urologist performs the dilation of a vesical neck contracture in a male patient under general anesthesia to improve bladder emptying.
7. A patient with a urethral stricture caused by previous prostate surgery undergoes dilation by a urologist under spinal anesthesia to alleviate urinary symptoms.
8. A urologist performs the dilation of a urethral stricture in a male patient with voiding difficulties under general anesthesia to improve urinary flow.
9. A patient with recurrent urinary tract infections undergoes dilation of a vesical neck narrowing by a urologist under spinal anesthesia to prevent further infections.
10. A urologist performs the dilation of a urethral stricture in a male patient with urinary incontinence under general anesthesia to restore normal urinary function.