How To Use CPT Code 53860

CPT 53860 describes a minimally invasive treatment for stress urinary incontinence in females. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53860?

CPT 53860 is a code used to describe a minimally invasive treatment for stress urinary incontinence in females. It involves the use of radiofrequency micro-remodeling to reduce the elasticity of the tissue in the bladder neck and proximal urethra. This procedure aims to improve continence and reduce the symptoms of stress urinary incontinence.

2. Official Description

The official description of CPT code 53860 is: ‘Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence.’

3. Procedure

In this procedure, a provider inserts a probe with a balloon tip into the bladder lumen through the urethra. The probe contains four tiny electrodes that are positioned in the submucosa of the bladder neck. The provider then delivers radiofrequency energy in a controlled manner for a 60-second cycle while irrigating the mucosa to prevent tissue heating. The treated tissue is maintained at 65 degrees Celsius for 30 seconds. The provider rotates and repositions the probe to repeat the procedure three times, ensuring that a total of 12 foci of collagen denaturation are achieved in the bladder neck and proximal urethra.

4. Qualifying circumstances

CPT 53860 is used for the treatment of stress urinary incontinence in females. It is performed on patients who have been appropriately prepped and anesthetized. The procedure is indicated for patients who have not responded to conservative treatments and require a minimally invasive intervention to improve continence.

5. When to use CPT code 53860

CPT code 53860 should be used when performing transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence. It is important to ensure that the procedure is performed on female patients and that the specific indications for stress urinary incontinence are met.

6. Documentation requirements

To support a claim for CPT 53860, the provider must document the following information:

• Patient’s diagnosis of stress urinary incontinence
• Details of the procedure performed, including the use of radiofrequency micro-remodeling
• Date of the procedure
• Duration of the procedure
• Specific areas of the bladder neck and proximal urethra treated
• Any complications or adverse events
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 53860, ensure that the procedure meets the specific criteria outlined in the official description. It is important to use the correct code for the treatment of stress urinary incontinence in females. Be aware of any additional guidelines or modifiers that may be required for accurate billing.

8. Historical information

CPT 53860 was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates to the code since its addition.

9. Examples

1. A provider performs transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for a patient with stress urinary incontinence.
2. A female patient undergoes CPT 53860 to address her symptoms of stress urinary incontinence that have not responded to conservative treatments.
3. A provider uses radiofrequency micro-remodeling to treat stress urinary incontinence in a female patient who desires a minimally invasive intervention.
4. CPT 53860 is performed on a patient with stress urinary incontinence to improve continence and reduce symptoms.
5. A female patient undergoes transurethral radiofrequency micro-remodeling of the bladder neck and proximal urethra to address her stress urinary incontinence.
6. A provider performs CPT 53860 on a patient who has failed conservative treatments for stress urinary incontinence and desires a minimally invasive intervention.
7. A female patient with stress urinary incontinence undergoes radiofrequency micro-remodeling of the bladder neck and proximal urethra to improve her continence.
8. CPT 53860 is performed on a patient with stress urinary incontinence to reduce symptoms and improve quality of life.
9. A provider uses transurethral radiofrequency micro-remodeling to treat stress urinary incontinence in a female patient who desires a less invasive option.
10. A female patient undergoes CPT 53860 to address her stress urinary incontinence and improve her continence.