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The procedure described by CPT® Code 53200 refers to a biopsy of the urethra, which is a diagnostic intervention aimed at obtaining tissue samples from the urethral area. This procedure is typically indicated when there is a visible lesion on the external aspect of the urethra that requires further investigation. During the biopsy, the healthcare provider will first conduct a visual inspection of the lesion to assess its characteristics. Following this, the surgical site is meticulously cleansed to minimize the risk of infection. A local anesthetic may be administered to ensure patient comfort during the procedure. The clinician then proceeds to obtain one or more tissue samples from the lesion. These samples are crucial for subsequent analysis, as they are prepared and examined by a pathologist in a separate procedure. The primary goal of this examination is to identify the presence of cancerous cells or other abnormal cellular changes, which can inform further management and treatment options for the patient.
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The biopsy of the urethra, as described by CPT® Code 53200, is indicated for the following conditions:
The procedure for a urethral biopsy involves several key steps that ensure the accurate collection of tissue samples.
Following the urethral biopsy, patients may be monitored for any immediate complications, such as bleeding or infection. It is important for patients to follow any post-procedure care instructions provided by their healthcare provider. Recovery time may vary, but patients are generally advised to avoid strenuous activities and to report any unusual symptoms, such as excessive pain or discharge, to their physician. The results of the tissue examination will be communicated to the patient, and further management will be discussed based on the findings.
| Short Descr | BIOPSY OF URETHRA | Medium Descr | BIOPSY URETHRA | Long Descr | Biopsy of urethra | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 100 - Endoscopy and endoscopic biopsy of the urinary tract |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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