The urethrotomy CPT Code procedure is described in CPT’s manual with CPT 52270, CPT 52275, CPT 52276, CPT 53000, and CPT 53010. Below the billing guidelines and descriptions of the CPT codes for Urethrotomy.
A patient is placed under general anesthesia during a urethrotomy CPT code procedure. Then, a cystourethroscope, a tube with a camera and light source, is inserted into the urethra to explore the urethra and the bladder and visualize urethra strictures.
The surgeon then makes an incision of the urethral stricture with the aid of a particular instrument called a urethrotome passed through the cystourethroscope. It helps primarily to relieve an obstruction of urine flow due to a structure or the presence of a foreign body.
It is worth noting that not all urethrotomy CPT code procedures are performed with a cystourethroscope. Although rarely, a surgeon can do a urethrotomy through an external opening made through an incision on the perineal or pendulous part of the urethra.
Therefore, the CPT codes for urethrotomy describe minimal invasive procedures that can be done with or without the aid of a cystourethroscope.
Procedures described by the CPT codes for urethrotomy are usually done with serial dilatation of the urethra with hegar dilators or following urethral stricture recurrence due to a failed urethroplasty.
Description Of The Urethrotomy CPT Codes
As already established, not all urethrotomy CPT code procedures involve the use of cystourethroscopes. This fact is essential to bear in mind because the appropriate CPT code for a urethrotomy procedure depends on using a cystourethroscope.
Internal Urethrotomy CPT Codes
Endoscopic/Internal Urethrotomy involves the incision of the urethra with the aid of a cystourethroscope or urethrotome to relieve a urethral stricture. It is described with three different CPT codes, which include;
CPT Code 52270
In internal urethrotomy CPT 52270, a physician examines the bladder, ureteral openings, and female urethra with a cystourethroscope passed via the urethra.
Subsequently, the surgeon incises any observed stricture with a cold knife called a urethrotome. It is used to report internal urethrotomy done in a female patient.
CPT’s manual officially describes the 52270 CPT code as: “Cystourethroscopy, with internal urethrotomy; female.”
CPT Code 52275
In internal urethrotomy CPT 52275, a cystourethroscope is passed through the male urethra to examine the bladder and urethra for abnormalities such as strictures. It is used to describe internal urethrotomy done in males only.
An incision is subsequently made on any observed stricture with a cold knife or urethrotome.
CPT’s manual officially describes the 52275 CPT code as: “Cystourethroscopy, with internal urethrotomy; male.”
CPT Code 52276
In the internal urethrotomy CPT 52276 procedure, a cystourethroscope is passed through the urethra to examine the bladder and urethra.
Strictures are incised with a urethrotome passed through a cystourethroscope under the supervision of a special telescope for direct vision. Hence, why it’s called a direct vision internal urethrotomy.
CPT 52276 is used for male and female direct visual internal urethrotomy with cystourethroscopy.
CPT’s manual officially describes the 52276 CPT code as: “Cystourethroscopy with direct vision internal urethrotomy.”
CPT Codes For Non-Endoscopic Urethrotomy
CPT codes for non-endoscopic urethrotomy involve an exploratory incision of the urethra not only for the treatment of stricture but also for the removal of foreign bodies in the urethra that might obstruct the flow of urine.
The description of this procedure is done with two different CPT codes, which include;
CPT Code 53000
CPT 53000 can be reported for non-endoscopic urethrotomy and describes the incision and repair of the pendulous part of the urethra for the treatment of a stricture.
CPT’s manual officially describes the 53000 CPT code as: “Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra.”
CPT Code 53010
CPT 53010 can be reported for non-endoscopic urethrotomy and describes a perineal urethrostomy where an exploratory incision and repair are done on the perineal urethra for stricture repair and foreign body removal.
The 53010 CPT code is also used to describe urethrostomy procedures of the perineal urethra.
CPT’s manual officially describes the 53010 CPT code as: “Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external.”
Billing Guidelines For The Urethrotomy CPT Codes
The urethrotomy CPT code that best defines each type of urethrotomy procedure should be used to bill for adequate reimbursement.
For example, CPT 51703, which codes for insertion of a temporary indwelling catheter, cannot be billed along with codes for urethrotomy. It is because the insertion of an indwelling urinary catheter is included as part of the Urethrotomy procedure.
When complications prolong the Urethrotomy procedure, an additional but necessary procedure is usually performed. Modifier 22 is indicated in this instance.
Suppose any non-endoscopic urethrotomy procedure such as penile Urethrotomy (CPT 53010) or pendulous urethrotomy (CPT 53000) is done with any endoscopic urethrotomy procedure (CPT 52270, CPT 52275, and CPT 52276). A urethrotomy CPT code be reported or billed separately in that case.
Modifier 59 (used to represent a distinct procedural service done along with the primary procedure) cannot be used in this case.
When billed together in the same session, the non-endoscopic urethrotomy CPT code procedures are usually bundled with endoscopic urethrotomy procedures such that only the endoscopic Urethrotomy procedures can be billed.
Sufficient documentation is required for adequate reimbursement of urethrotomy CPT code procedures.
The patient’s medical record must contain all supporting documents, including the indication for the procedure, which must be stored and made available upon request by payers or patients.
Reimbursement for urethrotomy CPT code procedures are as follows:
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How To Use Modifier 22 And Modifier 78 For Urethrotomy CPT Code Procedures
Modifier 22 can be reported for urethrotomy CPT code procedures to indicate when there is a substantial increase in the time and energy required.
It may be due to unforeseen removal of a foreign body during the urethra stricture repair or drainage of pus or other materials during a stricture repair.
For example, in a case where an exploratory incision of the urethra for the repair of strictures is complicated by a foreign body necessitating extra measures, modifier 22 is used to indicate the complication of the procedure.
To report a procedure with modifier 22, Medicare requires adequate documentation detailing substantial indications and requirements for its use because it is a rarely reimbursed modifier that can be overused.
The use of modifier 78 is indicated when a patient is returned to the operating room for an unplanned procedure carried out by the same physician, another physician, or qualified health personnel following an initial related primary procedure. In short, this unexpected procedure is done to correct an unintended outcome of the previous procedure.
Modifier 78 can be used for any subsequent unplanned urethrotomy CPT code procedure to report and correct a surgical procedure complication. Such a complication is reactionary hemorrhage which can occur within 24hrs of surgery.
For example: After a direct internal urethrotomy CPT code procedure, there was a reactionary hemorrhage 12 hrs later. The patient was taken back to the operating room to correct the bleeding.
This procedure should be appended with modifier 78 by the medical coder alongside the CPT code for the urethrostomy.
A 48-year-old man presented to the emergency room with features of acute urinary retention. A micturating cystourethrogram was done, which revealed a urethral stricture.
An incision of the urethral stricture was subsequently done with a urethrotome under a direct vision telescope. A urinary catheter was also passed to keep the urethra patent during healing.
This urethrostomy CPT code procedure is reported and billed as CPT code 52276.
The physician put a patient in a lithotomy position, and a cystourethroscope was passed to visualize the foreign body in the urethra. Unfortunately, all efforts to remove the foreign body proved abortive.
As a result, an exploratory incision of the perineal urethra was done to remove the foreign body, and a Foley catheter was placed in situ afterward.
This urethrostomy CPT code procedure is reported and billed as CPT 53010 with modifier 22 to indicate the complicated initial removal of the foreign body.
A 50 yr woman presents to the urology clinic with a history of weak urine stream, feeling of incomplete voiding, and a history suggestive of acute urinary retention.
A retrograde cystourethrogram was done, which revealed a urethral stricture. A cystourethroscope was passed through the urethra with a subsequent incision of the urethra stricture.
This urethrostomy CPT code procedure is reported and billed as CPT 52270.