Hi, would you bill the following using code 53450? The provider suggested 53430 but I think 53450 might be more appropriate. Thanks!
POSTOPERATIVE DIAGNOSIS: Urethral meatal stenosis.
PROCEDURE PERFORMED: Formal urethral meatoplasty
So, she received appropriate preoperative antibiotics in the holding area. She was taken to the operating room,
given the general anesthetic. A time-out was taken for identification purposes. She was then placed in
the dorsal lithotomy position, prepped and draped in a sterile fashion and her urethra was then calibrated
and again very snug at 18 to 20-French with female sounds. I was able to dilate up more than this and
then utilized a Spence clamp on the urethral meatus for about 1 cm to 1.5 cm and then cut this and the
urethra flayed opened and after that I was able to pass a 32-French female sound without any difficulty.
We then advanced the urethral mucosa toward the vaginal mucosa and pexed that together utilizing
interrupted 3-0 chromic ligatures. Once that was completed, then I felt that the urethral meatus was well
dilated and the stenosis was relieved. Hopefully this will take care of her problem and hopefully this will
assist in cutting down on her incidence of recurrent urinary tract infections. She tolerated the procedure
well and was returned to the recovery room in stable condition. LS 20220726
POSTOPERATIVE DIAGNOSIS: Urethral meatal stenosis.
PROCEDURE PERFORMED: Formal urethral meatoplasty
So, she received appropriate preoperative antibiotics in the holding area. She was taken to the operating room,
given the general anesthetic. A time-out was taken for identification purposes. She was then placed in
the dorsal lithotomy position, prepped and draped in a sterile fashion and her urethra was then calibrated
and again very snug at 18 to 20-French with female sounds. I was able to dilate up more than this and
then utilized a Spence clamp on the urethral meatus for about 1 cm to 1.5 cm and then cut this and the
urethra flayed opened and after that I was able to pass a 32-French female sound without any difficulty.
We then advanced the urethral mucosa toward the vaginal mucosa and pexed that together utilizing
interrupted 3-0 chromic ligatures. Once that was completed, then I felt that the urethral meatus was well
dilated and the stenosis was relieved. Hopefully this will take care of her problem and hopefully this will
assist in cutting down on her incidence of recurrent urinary tract infections. She tolerated the procedure
well and was returned to the recovery room in stable condition. LS 20220726