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2025 CPT code 53265

Excision or fulguration of a urethral caruncle.

Consult the most current CPT manual for detailed coding guidelines.Always report the specific service (excision or fulguration) along with any additional procedures performed during the same session.

Modifiers may apply depending on the circumstances of the procedure. Consult the current CPT manual for specific modifier guidelines.

Medical necessity for this procedure is established when a patient presents with symptoms directly attributable to a urethral caruncle, such as painful urination (dysuria), bleeding (hematuria), or urinary obstruction. Conservative management options should be considered and documented before resorting to surgical intervention.

The clinical responsibility for this procedure rests with a urologist or a surgeon experienced in urological procedures. The surgeon's duties involve evaluating the patient, determining the appropriate surgical approach (excision or fulguration), performing the procedure skillfully, ensuring proper hemostasis, and providing appropriate postoperative care, including catheter management (if applicable).

In simple words: The doctor removes a small, harmless growth (caruncle) from the urethra (the tube that carries urine from the bladder). This is done to ease painful urination and improve urination.The doctor might cut it out or use an electric current to destroy it.

This CPT code, 53265, encompasses the surgical excision or fulguration (destruction using electric current) of a urethral caruncle.A urethral caruncle is a benign, fleshy growth on the urethral meatus. The procedure aims to alleviate symptoms such as painful urination and improve urinary function.The approach varies depending on the patient's sex and the surgeon's preference. In females, access may involve a small incision in the anterior vaginal wall. In males, a transurethral approach is typically used.Following removal, a catheter may be placed to facilitate healing. Hemostasis (control of bleeding) and wound closure are standard components of the procedure.

Example 1: A 60-year-old female patient presents with painful urination and bleeding after urination.A urethral caruncle is identified during examination. Excision of the caruncle is performed under local anesthesia., A 45-year-old male patient complains of urinary irritation and discomfort. A urethral caruncle is diagnosed. Transurethral fulguration is performed under local anesthesia., A 72-year-old female patient undergoes a combined procedure.Cystoscopy is performed, revealing a urethral caruncle.The caruncle is then excised.

Complete patient history including symptoms (painful urination, bleeding, etc.), physical examination findings, diagnostic imaging (if any), intraoperative notes detailing the surgical technique (excision or fulguration), pathology report (if tissue sent for examination), postoperative course, and any complications.

** This code is used for the removal of benign urethral caruncles.It's crucial to differentiate this from malignant lesions, which have different coding requirements.

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