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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. In some cases, this condition may also be congenital, meaning it is present at birth. Patients experiencing urethral narrowing may present with a range of symptoms, such as 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 CPT® 53460 specifically involves a Richardson type approach, where a ventral incision is made in the penis, allowing for the removal of fibrous tissue that contributes to the narrowing of the distal urethra. Following this excision, the urethral opening is repaired to restore normal function.
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The procedure of urethromeatoplasty, specifically coded as CPT® 53460, is indicated for patients presenting with conditions that lead to urethral narrowing or meatal stenosis. The following are the explicitly provided indications for this procedure:
The urethromeatoplasty procedure, as described by CPT® 53460, involves several critical steps to effectively address the narrowing of the urethra. The following procedural steps are outlined:
Post-procedure care following urethromeatoplasty is essential for ensuring optimal recovery and function. Patients may be monitored for any signs of complications, such as infection or bleeding. It is important for patients to follow their healthcare provider's instructions regarding activity restrictions and wound care. Expected recovery may vary, but patients should anticipate some discomfort and swelling in the surgical area. Follow-up appointments will be necessary to assess healing and the success of the procedure, as well as to address any ongoing symptoms or concerns.
| Short Descr | REVISION OF URETHRA | Medium Descr | URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM | Long Descr | Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type 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) | 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 | 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). | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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