CPT Code for Repeat Urethral Dilation for Urethral Stricture
The correct CPT code for repeat urethral dilation for urethral stricture using saline solution instillation in a female patient is 53661.
Understanding the Procedure and Code Selection
When coding for urethral dilation procedures in female patients, the specific technique and purpose must be considered:
- 53660: Dilation of female urethra including suppository and/or instillation; initial
- 53661: Dilation of female urethra including suppository and/or instillation; subsequent
- 53665: Dilation of female urethra, general or conduction (spinal) anesthesia
In this case, the key factors determining the correct code are:
- This is a repeat (not initial) procedure
- The procedure involves instillation of saline solution
- The patient is female
Rationale for Code Selection
The American Urological Association guidelines support the use of urethral dilation as an appropriate treatment for urethral strictures 1. Since this is specifically noted as a "repeat" dilation procedure, code 53661 is the appropriate choice rather than 53660, which would be used for an initial dilation 1.
The use of saline solution instillation during the procedure further confirms that 53661 is the correct code, as this code specifically includes "instillation" in its descriptor.
Clinical Context
Urethral dilation is commonly performed for urethral strictures, with success rates ranging from 35-70% for short strictures (<2cm) 1, 2. The AUA guidelines indicate that dilation and direct visual internal urethrotomy (DVIU) can be used interchangeably for the treatment of urethral strictures, with similar success and complication rates 1.
Important Considerations
- For recurrent strictures, especially after failed dilation or DVIU, urethroplasty may be recommended due to high recurrence rates (>80%) with repeat endoscopic procedures 1
- Repeated endoscopic treatments may cause longer strictures and increase the complexity of subsequent urethroplasty 1
- For patients not suitable for urethroplasty, self-catheterization after dilation may help maintain temporary urethral patency 1
Coding Pitfalls to Avoid
- Do not use 53660 for repeat procedures (reserved for initial dilations)
- Do not use 53665 unless general or spinal anesthesia was used
- Do not use codes for male urethral dilation (53600,53601,53620,53621) for female patients
The evidence clearly supports 53661 as the appropriate CPT code for this specific clinical scenario of a repeat urethral dilation with saline instillation for urethral stricture in a female patient.