2025 CPT code 53405
Effective Date: N/A Surgery - Urinary System Surgery Feed
Second stage urethroplasty, including urinary diversion.
Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (22), reduced services (52), or staged procedures (58). Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity is established by the underlying condition requiring a two-stage urethroplasty, such as severe hypospadias, traumatic urethral injury, or complex stricture, where a single-stage repair is not feasible or carries significantly higher risk.
The surgeon reopens the previous incision, identifies the urethral flap (tissue used to reconstruct the urethra), forms the new urethral passage, sutures skin flaps to create a tube, inserts a Foley catheter for urine drainage, and closes the incision.
In simple words: This is the second surgery to repair a birth defect or injury to the urethra (the tube that carries urine out of the body). The surgeon creates a new tube for urine to flow through.
The second stage of a two-stage urethroplasty involves the formation of a new urethra, often utilizing a previously created flap or graft. This procedure includes urinary diversion, typically with a Foley catheter, and closure of the surgical site.
Example 1: A patient undergoes the second stage of a hypospadias repair, where the surgeon constructs the new urethra using a previously prepared flap., Following a traumatic urethral injury, a patient has a delayed second-stage urethroplasty to create a new urethral passage., A patient with a complex urethral stricture undergoes a staged urethroplasty, with 53405 representing the second stage where the urethra is reconstructed.
Documentation should include operative details of the second stage, including the type of repair, use of grafts or flaps, method of urinary diversion, and any complications encountered. The previous first-stage procedure should also be documented.
** Code 53400 is used for the first stage of urethroplasty for fistula, diverticulum, or stricture. If urethral damage occurs as a complication during another surgery and requires repair, the repair is billable with the primary procedure.
- Specialties:Urology, Pediatric Urology, Reconstructive Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center