Urology Coding Alert

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?


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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.