© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 53448 involves the removal and replacement of an inflatable urethral or bladder neck sphincter (AUS) in patients who have developed an infection related to the device. This complex surgical intervention is performed through the same incision site(s) used for the initial implantation of the AUS. The procedure is critical for patients experiencing complications due to infection, as it not only addresses the removal of the infected device but also ensures that a new device can be safely implanted. The process includes thorough irrigation and debridement of any infected tissue to promote healing and prevent further complications. The surgical approach varies between male and female patients, with specific techniques employed to access the device and surrounding structures. The procedure is designed to restore urinary function while managing the infection effectively, ensuring that the new AUS system can be placed in a clean surgical field.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 53448 is indicated for patients who require the removal and replacement of an inflatable urethral or bladder neck sphincter due to infection associated with the device. The following conditions may warrant this procedure:
The procedure for CPT® Code 53448 involves several detailed steps to ensure the safe removal and replacement of the AUS in an infected field:
Post-procedure care following the removal and replacement of the AUS includes monitoring for signs of infection, managing pain, and ensuring proper healing of the surgical sites. Patients may require follow-up visits to assess the functionality of the new AUS system and to monitor for any complications. Instructions regarding activity restrictions, catheter care, and signs of potential complications should be provided to the patient to ensure a smooth recovery process.
| Short Descr | REMOV/REPLC UR SPHINCTR COMP | Medium Descr | RMVL & RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD | Long Descr | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue | 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 | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 106 - Genitourinary incontinence procedures |
| 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | 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 |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2011-01-01 | Changed | Guideline information changed. |
| 2002-01-01 | Added | First appearance in code book in 2002. |
Get instant expert-level medical coding assistance.