Urology Coding Alert

YOU BE THE CODER:

Initial vs. Subsequent Dilations

Question: Is there a time limit on dilation of a urethral stricture with filiform and follower (CPT 53620) initial vs. subsequent (53621)? What makes it subsequent?


Utah Subscriber


Answer: You should report subsequent dilations using CPT 53621 (Dilation of urethral stricture by passage of filiform and follower, male; subsequent) when they are part of a planned dilation to a certain urethral caliber and size. Once this urethral caliber has been reached, the therapy is assumed completed.

Therefore, when the patient comes for a second course of dilations several months later, you should again report an initial dilation using 53620 (Dilation of urethral stricture by passage of filiform and follower, male; initial) for the first dilation. Use 53621 with subsequent dilations to complete this second course of therapy.

Important: The use of initial and subsequent does not mean that once a patient has one dilation, all following dilations for the rest of the patient's life are to be billed as subsequent dilations.

Which Codify by AAPC tool is right for you?

Call 844-334-2816 to speak with a Codify by AAPC specialist now.