How To Use CPT Code 53621

CPT 53621 describes the dilation of a urethral stricture in male patients using a filiform and follower during subsequent visits. 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 53621?

CPT 53621 is used to describe the dilation of a urethral stricture in male patients during subsequent visits. The procedure involves the passage of a filiform and follower to widen the narrowed area and improve urinary flow. This code is specifically used for subsequent visits, not the initial visit for this treatment.

2. Official Description

The official description of CPT code 53621 is: ‘Dilation of urethral stricture by passage of filiform and follower, male; subsequent.’

3. Procedure

1. During subsequent visits, the healthcare provider applies a lubricant and gently inserts a filiform device through the meatus, which is the urethral opening.
2. The provider then attaches different sizes of followers to the ends of the filiform to achieve the desired widening of the urethra.
3. This procedure aims to expand or widen the narrowed area of the urethra, typically using an instrument that can be expanded or a balloon on the tip of a catheter.

4. Qualifying circumstances

CPT 53621 is performed when symptoms of a urethral stricture recur in male patients. The provider uses a filiform and follower to dilate the stricture, improving urinary flow and preventing infection. It is important to note that this code is specifically for subsequent visits, not the initial visit for this treatment.

5. When to use CPT code 53621

CPT code 53621 should be used when a male patient presents for subsequent visits and requires dilation of a urethral stricture using a filiform and follower. It is important to use this code only for subsequent visits, not the initial visit for this treatment.

6. Documentation requirements

To support a claim for CPT 53621, the healthcare provider must document the following information:

• Reason for the procedure, including the recurrence of symptoms
• Details of the dilation procedure, including the use of a filiform and follower
• Date of the subsequent visit
• Any complications or adverse events that occurred during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 53621, ensure that the procedure is performed during a subsequent visit for the dilation of a urethral stricture in male patients using a filiform and follower. It is important to use the appropriate code for the initial visit (CPT 53620) or if the provider dilates the stricture using a sound or urethral dilator (CPT 53601). Report CPT 53621 separately and do not report it if CPT codes 53666 to 53665 have already been performed in the previous seven days.

8. Historical information

CPT 53621 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 male patient presents for a subsequent visit with recurrent symptoms of a urethral stricture. The healthcare provider performs dilation using a filiform and follower.
2. During a follow-up visit, a male patient experiences recurring symptoms of a urethral stricture. The healthcare provider uses a filiform and follower to dilate the stricture and improve urinary flow.
3. A male patient returns for a subsequent visit after experiencing symptoms of a urethral stricture. The healthcare provider performs dilation using a filiform and follower to alleviate the narrowing and improve urinary flow.
4. During a follow-up appointment, a male patient reports recurring symptoms of a urethral stricture. The healthcare provider performs dilation using a filiform and follower to widen the narrowed area and improve urinary flow.
5. A male patient visits the healthcare provider for a subsequent visit due to recurrent symptoms of a urethral stricture. The provider performs dilation using a filiform and follower to alleviate the narrowing and improve urinary flow.
6. During a follow-up visit, a male patient presents with recurring symptoms of a urethral stricture. The healthcare provider uses a filiform and follower to dilate the stricture and improve urinary flow.
7. A male patient returns for a subsequent visit after experiencing symptoms of a urethral stricture. The healthcare provider performs dilation using a filiform and follower to widen the narrowed area and improve urinary flow.
8. During a follow-up appointment, a male patient reports recurring symptoms of a urethral stricture. The healthcare provider performs dilation using a filiform and follower to alleviate the narrowing and improve urinary flow.
9. A male patient visits the healthcare provider for a subsequent visit due to recurrent symptoms of a urethral stricture. The provider performs dilation using a filiform and follower to alleviate the narrowing and improve urinary flow.
10. During a follow-up visit, a male patient presents with recurring symptoms of a urethral stricture. The healthcare provider uses a filiform and follower to dilate the stricture and improve urinary flow.