© Copyright 2025 American Medical Association. All rights reserved.
Urethromeatoplasty is a surgical procedure aimed at enlarging or reconstructing the urethral opening located at the distal tip of the penis, which is essential for facilitating urination. The urethra serves as the conduit for urine to exit the bladder and for sperm to be ejaculated, making its proper function critical for both urinary and reproductive health. Urethral narrowing, often referred to as meatal stenosis, can occur due to various factors, including scarring of the mucosal tissue resulting from irritation, inflammation, infection, or injury. Additionally, some individuals may be born with this condition, indicating a congenital origin. Symptoms associated with urethral narrowing can significantly impact a patient's quality of life and may include painful urination, frequent urges to urinate, difficulty in completely emptying the bladder, and abnormal urine flow patterns, such as upward or sideways discharge. The procedure coded as 53450 involves the surgical opening of the urethral meatus, followed by the creation of a mucosal flap that is sutured to the glans of the penis, thereby enhancing the urethral opening and alleviating the symptoms associated with meatal stenosis.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of urethromeatoplasty is indicated for patients experiencing symptoms related to urethral narrowing or meatal stenosis. The following conditions may warrant this surgical intervention:
The urethromeatoplasty procedure involves several critical steps to ensure successful reconstruction of the urethral opening. The following procedural steps are typically followed:
Following the urethromeatoplasty procedure, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for wound care, management of any discomfort, and guidelines for activity restrictions to promote healing. Patients may also be advised on signs of potential complications, such as infection or excessive bleeding, that would require prompt medical attention. Recovery time can vary, but patients are generally expected to follow up with their healthcare provider to assess the success of the procedure and ensure proper healing of the urethral opening.
| Short Descr | REVISION OF URETHRA | Medium Descr | URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT | Long Descr | Urethromeatoplasty, with mucosal advancement | 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) | 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). | 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.) | 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). | AG | Primary physician | 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 | KX | Requirements specified in the medical policy have been met | SG | Ambulatory surgical center (asc) facility service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.