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The procedure described by CPT® Code 53502 refers to urethrorrhaphy, which is the surgical repair of a wound or injury to the urethra in females. This procedure is essential for addressing injuries that may occur due to trauma, surgical complications, or other medical conditions affecting the urethra. The urethra is a critical structure in the female anatomy, responsible for the passage of urine from the bladder to the outside of the body. Surgical repair involves meticulous techniques to ensure proper healing and restoration of function. The procedure is performed with the patient positioned in dorsal lithotomy, which allows optimal access to the surgical site. The preparation of the vaginal area, including the vulva and perineum, is crucial to minimize the risk of infection. The surgical approach typically involves making an incision in the anterior vaginal wall to access the urethra, followed by careful dissection to identify the urethral defect. The repair process includes closing the mucosal and muscular layers of the urethra, ensuring that the integrity of the urethral structure is maintained. The use of absorbable sutures for closing the periurethral fascia and vaginal wall is standard practice, and a transurethral catheter is placed to facilitate healing and urinary drainage postoperatively. This procedure is vital for restoring normal urinary function and preventing complications associated with urethral injuries.
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The procedure of urethrorrhaphy (CPT® Code 53502) is indicated for the following conditions:
The surgical procedure for urethrorrhaphy involves several critical steps to ensure effective repair of the urethral injury:
After the urethrorrhaphy procedure, the patient will typically be monitored for any immediate complications. The urethral catheter remains in place for a specified duration to allow for proper healing and to ensure that urine can be drained without straining the repaired urethra. Patients may be advised on post-operative care, including signs of infection, pain management, and activity restrictions to promote recovery. Follow-up appointments are essential to assess the healing process and to remove the catheter when appropriate.
| Short Descr | REPAIR OF URETHRA INJURY | Medium Descr | URETHRORRHAPHY SUTR URETHRAL WOUND/INJ FEMALE | Long Descr | Urethrorrhaphy, suture of urethral wound or injury, female | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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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