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The procedure described by CPT® Code 53420 refers to a urethroplasty, specifically the first stage of a two-stage reconstruction or repair of the prostatic or membranous urethra. This surgical intervention is typically indicated for patients who have sustained injuries or trauma to the urethra, which may occur due to various factors such as pelvic fractures, prostate surgeries, or radiation therapy. The prostatic and membranous urethra are critical components of the urinary tract, extending from the bladder neck through the prostate gland and terminating at the bulbar segment. In this first stage of the procedure, a perineal approach is utilized, which involves making a midline incision in the perineal area. The surgical team dissects through the bulbospongiosum muscle to expose the corpus spongiosum and locate the urethra. If a stricture is present, the urethra is opened and resected to access healthy tissue at both ends. In cases of complete transection, the distal and proximal ends of the urethra are identified and brought together at the midline. A buccal mucosal graft, which has been prepared in advance, is then used to line the urethral defect or encase the urethral stumps. The graft is sutured to the edges of the perineal skin and around the urethral stumps, while urine is diverted through a suprapubic catheter that is typically not left in place after this stage. This initial stage sets the foundation for the subsequent second stage of the procedure, which is performed once the graft has adequately vascularized and epithelial tissue is observed at the perineum.
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The procedure described by CPT® Code 53420 is indicated for the following conditions:
The first stage of the urethroplasty procedure involves several critical steps:
After the completion of the first stage of the urethroplasty, the patient is monitored for recovery. The suprapubic catheter is used to divert urine during the healing process. It is essential to ensure that the graft has adequate vascularization and that epithelial tissue is visible at the perineum before proceeding to the second stage of the procedure. The patient may require follow-up appointments to assess healing and prepare for the subsequent surgical intervention.
| Short Descr | RECONSTRUCT URETHRA STAGE 1 | Medium Descr | URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE | Long Descr | Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage | 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) | 1 - Statutory payment restriction for assistants at surgery applies 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 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met |
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| 2011-01-01 | Changed | Short description changed. |
| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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