2025 CPT code 51841
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Urinary System Feed
Anterior vesicourethropexy or urethropexy (e.g., Marshall-Marchetti-Krantz, Burch); complicated (e.g., secondary repair).
Modifiers may be applicable. Modifier 22 (Increased Procedural Services) is appropriate if the procedure requires significantly more work than usual due to the complicating factors. Other modifiers may be applicable depending on the specific circumstances.
Medical necessity is established by the presence of stress urinary incontinence that has not responded to conservative treatments and is significantly impacting the patient's quality of life. The documentation should support the complexity of the procedure and the need for the more extensive surgery.
The surgeon's responsibilities include pre-operative evaluation and planning, obtaining informed consent, performing the surgical procedure, managing post-operative care, and addressing any complications.
In simple words: This procedure lifts and secures the bladder and urethra back into their normal position to treat urinary incontinence, especially when the procedure is more difficult due to scar tissue, bleeding, or other complications.
This code describes a complex anterior vesicourethropexy or urethropexy, which involves the surgical elevation and fixation of the bladder neck and urethra.It is used when the procedure is complicated by factors such as extensive dissection of adhesions, excessive bleeding, secondary repair, or other difficulties. The procedure aims to restore the urethrovesical angle and treat urinary incontinence.The approach may involve a Pfannenstiel incision or a vertical incision, and the surgeon may use techniques like the Marshall-Marchetti-Krantz (MMK) or Burch procedures to secure the bladder neck and urethra.Complicating factors that warrant the use of this code include excessive operative time, extensive bleeding, presence of adhesions from previous surgery, vaginal prolapse, a secondary repair, or patient obesity.
Example 1: A patient with stress urinary incontinence and a history of previous pelvic surgery presents with significant adhesions. The surgeon performs an anterior vesicourethropexy, requiring extensive dissection of the adhesions, thus justifying the use of code 51841., A patient with recurrent stress urinary incontinence undergoes a secondary anterior vesicourethropexy. The complexity of the repeat procedure and the need to address scar tissue from the previous surgery warrants the use of code 51841., An obese patient with stress urinary incontinence undergoes an anterior vesicourethropexy. The increased difficulty of the procedure due to the patient's body habitus, potentially leading to longer operative time and increased risk of complications, supports the use of 51841.
Documentation should clearly support the medical necessity of the complicated procedure, detailing the specific complicating factors encountered, such as extensive adhesions, excessive bleeding, secondary repair, or other difficulties. Operative time should be documented. Pre- and post-operative diagnoses, including the type of incontinence, should be included.
- Specialties:Urology, Urogynecology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center