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The procedure described by CPT® Code 53431 is known as urethroplasty with tubularization of the posterior urethra and/or lower bladder, specifically aimed at addressing incontinence issues. Incontinence refers to the involuntary loss of urine, which can significantly impact a patient's quality of life. During this surgical intervention, the physician utilizes muscle tissue from the bladder to lengthen the urethra or the lower section of the bladder. This technique is particularly relevant in cases where traditional methods have failed or are not suitable. The procedure may involve techniques such as the Tenago or Leadbetter procedures, which are designed to enhance the structural integrity of the urethra and improve urinary control. By reinforcing the urethra or bladder, the surgery aims to restore normal function and alleviate the symptoms associated with urinary incontinence.
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The procedure is indicated for patients experiencing urinary incontinence, which is characterized by the inability to control the release of urine. This condition may arise from various underlying issues, including anatomical abnormalities, previous surgical complications, or neurological disorders that affect bladder control.
The urethroplasty with tubularization of the posterior urethra and/or lower bladder involves several critical steps to ensure the successful correction of incontinence.
After the procedure, patients are typically monitored for any immediate complications. Post-operative care may include pain management, instructions for activity restrictions, and follow-up appointments to assess healing and urinary function. Patients may also be advised on fluid intake and bladder training exercises to support recovery. The expected recovery time can vary, but many patients can return to normal activities within a few weeks, depending on individual healing and the complexity of the surgery.
| Short Descr | RECONSTRUCT URETHRA/BLADDER | Medium Descr | URTP W/TUBULARIZATION POST URT&/LWR BLDR | Long Descr | Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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) | P1G - Major procedure - 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). | 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. | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2002-01-01 | Added | First appearance in code book in 2002. |
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