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The procedure described by CPT® Code 53442 involves the removal or revision of a urethral sling specifically designed for male urinary incontinence. This surgical intervention is typically indicated in cases where the sling has failed to provide the intended support, has caused pain, or has led to infection. The urethral sling, which may be made from either fascia or synthetic materials, is a device implanted to help manage urinary incontinence by providing support to the urethra. Although the need for removal or revision of the sling is uncommon, it is a critical procedure when complications arise. The surgical approach requires careful dissection and manipulation of surrounding tissues to minimize the risk of injury to the urethra and adjacent blood vessels. The procedure is performed under anesthesia and involves both perineal and abdominal incisions to access and manage the sling effectively. The complexity of this procedure necessitates a thorough understanding of the anatomy involved and the potential complications that may arise during and after the surgery.
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The removal or revision of a urethral sling for male urinary incontinence is indicated in specific circumstances where the initial surgical intervention has not achieved the desired outcomes. The following conditions may warrant this procedure:
The procedure for the removal or revision of the urethral sling involves several critical steps to ensure proper management of the device and surrounding tissues. The following procedural steps are outlined:
After the removal or revision of the urethral sling, patients may require specific post-procedure care to ensure optimal recovery. This includes monitoring for any signs of infection, managing pain, and ensuring proper drainage through any placed drains. Patients are typically advised on activity restrictions to promote healing and prevent complications. Follow-up appointments are essential to assess the surgical site, evaluate urinary function, and address any concerns that may arise during the recovery period. The healthcare team will provide guidance on when normal activities can be resumed and any additional care that may be necessary.
| Short Descr | REMOVE/REVISE MALE SLING | Medium Descr | RMVL/REVJ SLING MALE URINARY INCONTINENCE | Long Descr | Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) | 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) | 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 | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 106 - Genitourinary incontinence procedures |
| 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. | 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. | 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). | 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). | 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 | 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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| 2003-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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