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2025 CPT code 51990

Laparoscopic surgical urethral suspension for stress incontinence.

Appropriate coding requires thorough documentation of the pre-operative diagnosis, the procedure performed, and post-operative recovery.The procedure must be medically necessary; this means the patient must have stress incontinence before the surgery. The modifier -59 may be used in specific circumstances where the urethral suspension is a distinct procedural service but requires supporting documentation.

Modifiers may apply depending on circumstances; consult current CPT guidelines and payer specific rules. For example, modifier -59 may be used if the procedure is considered distinct from another procedure performed during the same encounter, but requires supporting documentation.

The procedure is medically necessary when conservative treatment options (e.g., pelvic floor exercises, medications) have failed to provide adequate relief of stress urinary incontinence. The patient's symptoms should significantly impair their quality of life.

The surgeon is responsible for all aspects of the procedure, including patient preparation, anesthesia administration (if applicable), laparoscopic visualization, urethral suspension using sutures, hemostasis, and wound closure.

IMPORTANT:Other procedures for stress incontinence include 57288 (sling operation), 51715 (endoscopic injection), 51840 (anterior vesicourethropexy), 51845 (abdomino-vaginal vesical neck suspension), 51992 (laparoscopic sling operation), and 58267 (vaginal hysterectomy with colpourethrocystopexy).

In simple words: This surgery uses a tiny camera and small cuts to lift and support the urethra (the tube that carries urine from the bladder) to help stop urine leakage.

This laparoscopic procedure involves surgically suspending the urethra by placing sutures and attaching it to the surrounding tissue.A laparoscope (a thin tube with a camera) is inserted through a small incision to visualize the urethra and bladder. Additional incisions allow for the insertion of surgical instruments to perform the suspension. The procedure is used to treat stress urinary incontinence, the inability to control urine.

Example 1: A 55-year-old female patient presents with stress incontinence after childbirth.Laparoscopic urethral suspension is performed to correct the condition., A 60-year-old female patient experiences stress incontinence due to pelvic floor weakness.A laparoscopic urethral suspension is performed during a laparoscopic hysterectomy (with appropriate coding for both procedures)., A 70-year-old female experiences post-menopausal stress incontinence.A laparoscopic urethral suspension is chosen due to minimal invasiveness.

* Preoperative evaluation including history and physical examination, focusing on urinary symptoms and pelvic floor examination.* Operative report detailing the procedure performed including number and location of incisions, method of urethral suspension and materials used, and estimated blood loss.* Postoperative recovery notes documenting complications if any.* Documentation supporting medical necessity, clearly demonstrating the patient's symptoms and the need for this procedure to alleviate the urinary incontinence.

** The use of this code should always be supported by thorough documentation demonstrating the medical necessity of the procedure for treating pre-existing stress urinary incontinence.Improper use might lead to denial of claims.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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