© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 53605 involves the dilation of a urethral stricture or the vesical neck in male patients. This is a surgical intervention performed under general or conduction (spinal) anesthesia, ensuring that the patient is adequately sedated and pain-free during the procedure. The male patient is positioned in a dorsal lithotomy position, which allows for optimal access to the urethra. Prior to the procedure, the penis and scrotum are meticulously prepared and draped to maintain a sterile environment. The dilation process itself is carried out using specialized instruments known as urethral sounds or S-curve urethral dilators. These instruments are introduced into the urethra in a sequential manner, starting with smaller sizes and gradually increasing in thickness. This careful and methodical approach aims to widen the narrowed area of the urethra or vesical neck, thereby alleviating any obstruction. Following the dilation, a catheter is placed transurethrally to facilitate urine drainage and support the healing process. This procedure is essential for patients suffering from urethral strictures, which can lead to significant urinary complications if left untreated.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure indicated by CPT® Code 53605 is performed for specific conditions related to the male urinary tract. These indications include:
The procedure for dilation of the urethral stricture or vesical neck is conducted through a series of well-defined steps:
Post-procedure care following the dilation of urethral stricture or vesical neck involves monitoring the patient for any immediate complications, such as bleeding or infection. The catheter placed during the procedure typically remains in place for a specified duration to ensure proper urine drainage and to allow the urethra to heal adequately. Patients may be advised on hydration and follow-up appointments to assess the success of the procedure and to monitor for any recurrence of symptoms. It is important for healthcare providers to provide clear instructions regarding signs of complications that the patient should report, such as increased pain, fever, or changes in urinary output.
| Short Descr | DILATE URETHRA STRICTURE | Medium Descr | DILAT URETHRAL STRIX/VESICAL NCK DILAT MALE ANES | Long Descr | Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | 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.) | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.