2025 CPT code 53400
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Surgical Procedures on the Urinary System Surgery Feed
Urethroplasty; first stage, for fistula, diverticulum, or stricture.
Modifiers may apply depending on the specific circumstances of the procedure. Consult the CPT manual for appropriate modifier usage.
Medical necessity for 53400 is established when a patient presents with a symptomatic urethral fistula, diverticulum, or stricture that significantly impairs urinary flow. This impairment must be documented through clinical findings (e.g., dysuria, urinary retention, recurrent infections) and imaging studies.
The urologist identifies and repairs the urethral defect. This may involve the use of imaging techniques such as urethrography, surgical incision and repair, and placement of a catheter for post-operative drainage and healing.
In simple words: This is the first part of a two-part surgery to repair a problem with the urethra, the tube that carries urine from the bladder.The surgeon finds and opens the damaged area, removes any blockage, and stitches the edges together.A tube may be left in place to help healing.
This CPT code 53400 represents the first stage of a two-stage urethroplasty.The procedure involves identifying and opening a urethral defect (fistula, diverticulum, or stricture), removing obstructing tissue, and suturing the mucosal edges of the urethra to the skin. This often includes the use of a catheter and/or urethrography (radiographic imaging of the urethra after contrast injection) to visualize the defect. A transurethral suprapubic incision is made, extended to the fascia and muscle, and then an incision over the defect allows for the raising of a skin flap.The flap is sutured with surrounding fascia and mucosa. A catheter is typically left in place to promote healing. Hemostasis is achieved before layered closure of the suprapubic incision.
Example 1: A patient presents with a urethral stricture causing urinary retention and dysuria.The surgeon performs a 53400 procedure as the first step in a two-stage urethroplasty to reconstruct the affected section of urethra., A patient with a history of urethral trauma sustains a fistula.The surgeon uses 53400 to initiate repair of the fistula, opening the tract and preparing the tissue for subsequent reconstruction., A patient is diagnosed with a urethral diverticulum causing recurrent urinary tract infections. The surgeon utilizes 53400 to excise the diverticulum and prepare the urethra for the next stage of repair.
* Preoperative diagnosis (e.g., urethral stricture, fistula, diverticulum).* Detailed operative report describing the surgical approach, techniques used, and tissue handled.* Imaging studies (e.g., urethrogram) demonstrating the location and extent of the defect.* Intraoperative photographs (if applicable).* Postoperative course notes.
** This code is for the first stage of a two-stage urethroplasty.The second stage is coded separately (53405).
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: This information is not available in the provided source.
- Global Days: This information is not available in the provided source.
- Payment Status: Active
- Modifier TC rule: This information is not available in the provided source.
- Fee Schedule: This information is not available in the provided source.
- Specialties:Urology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient/Outpatient)