How To Use CPT Code 53665

CPT 53665 describes the dilation of the female urethra using general or conduction anesthesia. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53665?

CPT 53665 involves the widening of the female urethra to allow for proper passage of urine. This procedure is performed under general or conduction anesthesia. The physician inserts dilators of increasing size to dilate the urethra and relieve urethral strictures. Suppositories or instillations may also be used to aid in the dilation process.

2. Official Description

The official description of CPT code 53665 is the dilation of the female urethra using general or conduction anesthesia. This code should be used for procedures that involve the insertion of dilators to widen the urethra and promote complete voiding of the bladder in patients with voiding problems. It is important to note that this code does not cover urethral catheterization or dilation performed under local anesthesia.

3. Procedure

1. The physician begins by assessing the patient’s condition and determining the need for urethral dilation.
2. General or conduction anesthesia is administered to ensure the patient’s comfort during the procedure.
3. The physician lubricates the area and inserts dilators of different diameters into the urethra.
4. The dilators are gradually increased in size to widen the urethra and relieve any strictures.
5. If necessary, suppositories or instillations may be used to aid in the dilation process.
6. Once the desired dilation is achieved, the dilators are removed, and the procedure is complete.

4. Qualifying circumstances

CPT 53665 is performed on female patients with urethral strictures that require dilation. Urethral strictures can occur due to injury or infection, causing a narrowing of the urethra. The procedure is typically performed by a physician under general or conduction anesthesia.

5. When to use CPT code 53665

CPT code 53665 should be used when performing the dilation of the female urethra using general or conduction anesthesia. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure involves urethral catheterization or dilation under local anesthesia, different codes should be used.

6. Documentation requirements

To support a claim for CPT 53665, the following documentation should be included:

• Patient’s diagnosis and the need for urethral dilation
• Details of the procedure, including the use of general or conduction anesthesia
• Specific dilators used and any additional medications or instillations administered
• Date and duration of the procedure
• Any complications or adverse events that occurred
• Physician’s signature and credentials

7. Billing guidelines

When billing for CPT 53665, ensure that the procedure meets the criteria outlined in the code description. It is important to use the appropriate anesthesia modifier to indicate whether general or conduction anesthesia was used. Additionally, be aware of any bundling or unbundling guidelines that may apply to the specific case. It is recommended to review the payer’s guidelines and consult with a coding specialist if necessary.

8. Historical information

CPT 53665 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 physician performs the dilation of the female urethra using general anesthesia to relieve a urethral stricture in a patient.
2. Under conduction anesthesia, a urologist inserts dilators to widen the urethra and promote complete voiding of the bladder in a female patient with voiding problems.
3. A gynecologist performs the dilation of the female urethra using general anesthesia to treat a patient with urethral strictures.
4. Using general anesthesia, a surgeon inserts dilators of progressively increasing size to widen the urethra and relieve a urethral stricture in a female patient.
5. Under conduction anesthesia, a urologist performs the dilation of the female urethra to treat a patient with voiding difficulties.
6. A physician uses general anesthesia to perform the dilation of the female urethra in a patient with urethral strictures.
7. Under conduction anesthesia, a urologist inserts dilators to widen the urethra and relieve a urethral stricture in a female patient.
8. A gynecologist performs the dilation of the female urethra using general anesthesia to treat a patient with urethral strictures.
9. Using general anesthesia, a surgeon inserts dilators of progressively increasing size to widen the urethra and relieve a urethral stricture in a female patient.
10. Under conduction anesthesia, a urologist performs the dilation of the female urethra to treat a patient with voiding difficulties.