2025 CPT code 53430
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Urinary System Surgery Feed
Urethroplasty; reconstruction of the female urethra.
Modifiers may apply depending on the circumstances of the procedure, such as multiple procedures (modifier 51), reduced services (modifier 52), or assistant surgeon (modifier 80).
Medical necessity is established based on the presence of a urethral defect causing symptoms like recurrent urinary tract infections, pain, or obstructed urination. The procedure is deemed medically necessary when conservative measures have failed or are inappropriate.
The clinical responsibility involves prepping and anesthetizing the patient, making incisions, preparing and suturing the vaginal flap to the urethra, placing an indwelling catheter, controlling bleeding, and closing the incision.
In simple words: This surgery repairs a damaged urethra (the tube that carries urine from the bladder). The surgeon uses tissue from the vagina or nearby area to fix the damage, which helps prevent infection and pain.
Urethroplasty is a surgical procedure to reconstruct the female urethra.It involves grafting tissue from the perineal or vaginal epithelium to repair a urethral defect, preventing infection and relieving pain. The procedure includes making an inverted U-shaped incision in the vaginal epithelium, extending from the urethral meatus to the anterior vaginal wall. A vaginal flap is prepared and used for urethral repair.The flap is sutured to the defective urethra in a double-layered, edge-to-edge fashion. An indwelling catheter is typically placed post-operatively, and bleeding is controlled before closing the external incision.
Example 1: A 35-year-old female presents with recurrent urinary tract infections and pain during urination due to a urethral stricture.Urethroplasty with vaginal graft is performed to reconstruct the urethra and relieve symptoms., A 40-year-old female patient underwent previous pelvic surgery resulting in urethral damage.Urethroplasty is performed using a perineal graft to correct the defect and restore normal urinary function., A 28-year-old female with congenital urethral anomaly undergoes urethroplasty using a vaginal mucosal graft to create a functional urethra, improving urinary flow and reducing the risk of complications.
* Preoperative assessment including patient history, physical exam, and imaging studies (e.g., urethroscopy, cystourethroscopy).* Intraoperative notes detailing surgical technique, tissue used for grafting, and placement of indwelling catheter.* Postoperative assessment including catheter management, pain control, and follow-up imaging if needed.* Pathology reports, if applicable.
** This code is specifically for female urethral reconstruction.For male urethroplasty, different codes apply.The choice of graft material (perineal or vaginal) depends on the specific clinical situation and surgeon preference.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:Urology, Gynecology
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital