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The CPT® Code 53453 refers to the removal of a periurethral transperineal adjustable balloon continence device, specifically addressing each balloon involved in the procedure. This device is primarily utilized in the management of urinary incontinence, particularly in male patients who have experienced incontinence following prostate surgery or radiation therapy. The purpose of the device is to restore normal pelvic pressure and urinary continence by providing adjustable support to the urethra. The procedure involves a series of steps that include the insertion of a cystoscope through the urethra into the bladder, followed by the use of a trocar and sheath to create a small incision in the perineum. This allows for the placement of the balloon device, which is inflated to secure its position. The device can be adjusted post-operatively by adding fluid to the balloon, ensuring that the pressure is adequate for optimal function. When removal of the device is necessary, a small incision is again made in the perineum, the balloon is deflated, and the device is carefully dissected from the surrounding tissue before being extracted. This procedure is critical for patients seeking relief from the complications of urinary incontinence, providing a means to manage their condition effectively.
© Copyright 2025 Coding Ahead. All rights reserved.
The periurethral transperineal adjustable balloon continence device is indicated for use in male patients experiencing urinary incontinence, particularly following prostate surgery and/or radiation therapy. This device aims to restore normal pelvic pressure and urinary continence, addressing the complications that may arise from these medical interventions.
The procedure for the placement and subsequent removal of the periurethral transperineal adjustable balloon continence device involves several detailed steps. Initially, a cystoscope is introduced through the urethra into the bladder to visualize the area. Following this, a sharp-tipped trocar and sheath are assembled, and a small incision is made in the perineum to facilitate access. Under fluoroscopic guidance, the trocar and sheath are inserted through the incision and advanced through the pelvic floor. Once the trocar reaches the bladder, it is replaced with a blunt-tipped trocar to continue the advancement safely. After the trocar is removed, the deflated balloon device is advanced through the sheath to the predetermined location. The sheath is then partially retracted, and the balloon is inflated with a small volume of fluid to secure it in place. After the inflation, the sheath is removed, and the perineum is closed. If bilateral placement is required, the entire procedure is repeated on the opposite side. Post-operatively, after a recovery period of a few weeks, the device can be accessed through a needle inserted into the perineum, allowing for additional fluid to be added to adjust the balloon volume for optimal pressure. This adjustment can be performed multiple times until the desired inflation volume is achieved. When the device needs to be removed, a small incision is again made in the perineum, the balloon is deflated, and the device is carefully dissected free from the surrounding tissue before being removed.
After the procedure, patients typically undergo a recovery period during which they may experience some discomfort at the incision site. It is essential to monitor for any signs of infection or complications. The device can be accessed for adjustments after a few weeks, allowing for the inflation volume to be modified as needed to ensure adequate pressure for urinary continence. Patients should follow up with their healthcare provider to assess the effectiveness of the device and to determine if further adjustments or interventions are necessary. Proper care of the incision site and adherence to post-operative instructions are crucial for optimal recovery and device function.
| Short Descr | TPRNL BALO CNTNC DEV RMVL EA | Medium Descr | PERIURETHRAL TPRNL ADJTBL BALO CNTNC DEV RMVL EA | Long Descr | Periurethral transperineal adjustable balloon continence device; removal, each balloon | Status Code | Carriers Price the Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No 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) | 0 - 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 | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | none | MUE | 2 |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 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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| 2022-01-01 | Added | Code added |
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