© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 53265 involves the excision or fulguration of a urethral caruncle, which is a small, benign growth that can occur at the external urethral opening in both men and women. This condition may lead to symptoms such as discomfort, bleeding, or urinary issues, prompting the need for surgical intervention. The removal can be accomplished through excision, which involves cutting away the caruncle, or fulguration, a technique that utilizes heat generated by an electrocautery device or laser to destroy the abnormal tissue. The procedure is typically performed in a controlled surgical environment, with the patient positioned appropriately to allow for optimal access to the urethral area. In females, the dorsal lithotomy position is commonly used, while males are positioned supine. The surgical site is meticulously prepared and draped to maintain a sterile field. The excision process involves careful handling of the surrounding tissues to minimize trauma and ensure proper healing. Following the removal of the caruncle, the urethral mucosa and vestibular epithelium are sutured together, and in some cases, a Foley catheter may be placed to facilitate urinary drainage during the recovery period. This procedure is essential for alleviating symptoms associated with urethral caruncles and restoring normal urinary function.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure for excision or fulguration of a urethral caruncle is indicated for patients presenting with specific symptoms or conditions related to the growth. These indications include:
The procedure for excision or fulguration of a urethral caruncle involves several key steps, which are detailed as follows:
After the excision or fulguration of the urethral caruncle, patients may require specific post-procedure care to ensure proper healing and recovery. It is common for patients to experience some discomfort or mild pain at the surgical site, which can typically be managed with prescribed analgesics. Monitoring for any signs of infection, such as increased redness, swelling, or discharge, is essential. The Foley catheter, if placed, may remain in situ for a short period to assist with urinary drainage, and patients should be advised on how to care for the catheter during this time. Follow-up appointments may be scheduled to assess healing and address any concerns. Patients are also encouraged to report any unusual symptoms, such as persistent bleeding or severe pain, to their healthcare provider promptly.
| Short Descr | TREATMENT OF URETHRA LESION | Medium Descr | EXC/FULGURATION URETHRAL CARUNCLE | Long Descr | Excision or fulguration; urethral caruncle | Status Code | Active Code | Global Days | 010 - 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 109 - Procedures on the urethra |
| 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). | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.