2025 CPT code 53449
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Urinary System Surgery Feed
Repair of an inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 22 for increased procedural service, modifier 51 for multiple procedures if cystoscopy is performed concurrently).
The medical necessity for code 53449 is established when the patient has an implanted artificial urinary sphincter and is experiencing complications such as cuff erosion or tissue atrophy, significantly impacting their urinary control and quality of life. The repair is medically necessary to restore function and alleviate symptoms.
The surgeon's responsibilities include pre-operative assessment, surgical repair of the artificial urinary sphincter (including any necessary adjustments or repositioning),hemostasis (control of bleeding), wound closure, and post-operative care instructions. Concurrent cystoscopy may be part of the surgical procedure.
In simple words: This code describes the surgical repair of a device used to control bladder leakage. The doctor fixes problems with the device, such as tissue damage or wear and tear on the device itself.This might involve adjusting the device's pressure, changing its position, or repairing a tear.
This CPT code encompasses the surgical repair of a previously implanted inflatable urethral or bladder neck sphincter.The repair addresses complications such as tissue atrophy or cuff erosion. The procedure involves reopening the incision, evaluating the sphincter, adjusting balloon pressure (if atrophy is present), repositioning the cuff if necessary, repairing any erosion, reapproximating tissues, controlling bleeding, and closing the incision.Cystoscopy (52000) may be performed concurrently to assess the condition of the sphincter cuff.If the sphincter is removed and replaced due to complications, codes 53447 or 53448 may be more appropriate.
Example 1: A 65-year-old male patient presents with worsening urinary incontinence six months after implantation of an artificial urinary sphincter.Cystoscopy reveals cuff erosion. The surgeon performs repair of the sphincter using code 53449., A 72-year-old female patient reports increasing difficulty with the operation of her artificial urinary sphincter.Physical examination reveals tissue atrophy around the cuff. The surgeon adjusts the balloon pressure and repairs minor erosion, billing with code 53449., A 58-year-old male patient experienced a malfunction of his artificial urinary sphincter that required a complex surgical repair, including cuff repositioning and tissue augmentation. The surgeon uses code 53449 to reflect the extensive nature of the repair.
Preoperative diagnosis indicating the need for repair (e.g., urinary incontinence, cuff erosion, tissue atrophy), operative report detailing the procedure performed (including specifics on the repair, any cuff adjustments, cystoscopy if performed), post-operative notes verifying the successful repair and patient outcome.
** Always consult the most current CPT manual and NCCI edits for accurate coding and reimbursement.The use of this code requires detailed documentation supporting medical necessity and the extent of the surgical repair.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Payment Status: Active
- Modifier TC rule: No information available.Refer to the NCCI edits for specific modifier rules.
- Specialties:Urology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Hospital Outpatient