Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
Excision of a urethral diverticulum in males, as described by CPT® Code 53235, refers to a surgical procedure aimed at removing a diverticulum, which is an abnormal pouch or sac that can form in the urethra. Male urethral diverticula are relatively uncommon and are typically located in the proximal region of the penile urethra or the distal part of the bulbous urethra. The procedure begins with the patient being properly prepped and draped to maintain a sterile environment. A catheter is inserted transurethrally to facilitate access and visualization during the surgery. An incision is made in the skin to expose the underlying corpus spongiosum, which is the erectile tissue surrounding the urethra. The surgeon then carefully dissects the diverticular sac away from the corpus spongiosum, ensuring that any surrounding attenuated tissue at the ostia, or opening of the diverticulum, is also removed. After the diverticulum is excised, the muscular and mucosal layers of the urethral defect are closed vertically over the catheter to restore the integrity of the urethra. In some cases, drains may be placed to prevent fluid accumulation. The corpus spongiosum is then sutured closed, followed by the closure of the skin incision. Finally, the urethral catheter is left in place to aid in urinary drainage during the initial recovery period.
© Copyright 2026 Coding Ahead. All rights reserved.
Excision of urethral diverticulum (CPT® Code 53235) is indicated for the following conditions:
The procedure for excision of a urethral diverticulum involves several critical steps:
Post-procedure care following the excision of a urethral diverticulum includes monitoring for any signs of complications such as infection or excessive bleeding. The patient may experience discomfort or pain, which can be managed with appropriate analgesics. The urethral catheter will typically remain in place for a specified duration to ensure proper urinary drainage and to allow the surgical site to heal. Follow-up appointments are essential to assess the healing process and to remove the catheter when deemed appropriate by the healthcare provider. Patients should be advised on signs of potential complications, such as fever, increased pain, or changes in urinary output, and instructed to seek medical attention if these occur.
| Short Descr | REMOVAL OF URETHRA LESION | Medium Descr | EXC URETHRAL DIVERTICULUM SPX MALE | Long Descr | Excision of urethral diverticulum (separate procedure); male | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 109 - Procedures on the urethra |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.