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Dilation of the female urethra is a medical procedure aimed at treating a narrowing or stricture of the urethra, which can occur due to various factors such as injury, scarring, congenital anomalies, or other underlying conditions. The procedure involves the careful cleansing of the urethral opening to prepare for intervention. To ensure patient comfort, a local anesthetic may be applied in the form of a suppository, jelly, or liquid to numb the area. Alternatively, the procedure can be performed under general anesthesia or conduction (spinal) anesthesia, which provides a deeper level of sedation and pain relief. During the dilation, a series of tubes or dilators are introduced through the urethral opening and advanced to the urethrovesical junction, effectively increasing the diameter of the narrowed segment of the urethra. A urethroscope may be utilized to guide the dilators accurately. After the dilation is completed, a catheter may be inserted and left in place to facilitate bladder drainage, ensuring that the patient can void comfortably during the recovery period. This procedure is coded as CPT® 53665 when performed under general or conduction anesthesia, distinguishing it from other related codes that specify different anesthesia methods or procedural contexts.
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The dilation of the female urethra is indicated for several specific conditions that lead to urethral narrowing or stricture. These indications include:
The procedure for dilation of the female urethra involves several key steps that ensure effective treatment of the stricture. These steps include:
After the dilation procedure, patients may experience some discomfort, which is typically managed with appropriate pain relief measures. The catheter, if placed, is usually left in situ for a specified duration to allow the urethra to heal and to ensure proper bladder drainage. Patients are monitored for any complications, such as bleeding or infection, and are provided with instructions for post-procedure care, including signs to watch for that may indicate complications. Follow-up appointments may be scheduled to assess the success of the dilation and to determine if further intervention is necessary.
| Short Descr | DILATION OF URETHRA | Medium Descr | DILAT FEMALE URETHRA GENERAL/CNDJ SPINAL ANES | Long Descr | Dilation of female urethra, 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). | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | 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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