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Basics of CPT code for Cystourethroscopy

In this procedure the physician treats the ureteral stricture by ballon dilation, laser, electrocautery or incision through a cystourethroscope. A flexible or rigid cystourethroscope is passed through the urethra into the bladder. A catheter with balloon is placed into the uretheral stricture and the balloon is gently inflated. In medical coding, there are specific CPT code for Cystourethroscopy which are used in surgery facility. CPT code 52341, 52342, 52343, 52344 & 52345 are used for coding cystourethroscopy.

Today we will check the diagnosis and the procedures related to Cystourethroscopy procedures.

Coding guide for CPT code for Cystourethroscopy

Top ICD-10 codes series CPT code for Cystourethroscopy

R31 Hematuria 20.27%
C67 Malignant neoplasm of bladder 19.56%
N40 Benign prostatic hyperplasia 14.21%
Z85 Personal history of malignant neoplasm 9.65%
N39 Other disorders of urinary system 6.67%

Coding tips for CPT code 36901 for AV Fistula Access

Procedure done for Cystourethroscopy CPT code

Their is common basic procedure done for cystourethroscopy exams, which will give you and information about how the exam is performed on the patient using equipments. Below is the short information on this.

“The patient is placed in the dorsal lithotomy position on the cystoscopy table, prepared, and draped. Local anesthetic jelly is injected into the urethra. The endoscopic equipment is assembled and connected to the video system. Defogger is applied to lenses and the video source. The irrigation source is connected, and the light source and white balance are connected.

The endoscope is inserted into the urethra, and relevant urethral anatomy is inspected, including the external urinary sphincter. The bladder neck is assessed, the trigone is inspected, and the ureteral orifices are identified (size, location). A check for efflux of urine from each ureteral orifice is made. The bladder mucosa (trabeculation, cellules, diverticuli, lesions, stones) is inspected, and bladder capacity, compliance, and sensation are assessed. A retroflex scope, if flexible, is used to inspect the bladder’s dome. The bladder is drained, and the endoscope is removed.”

Description of CPT code 52341, 52342, 52343, 52344 & 52345

In this exam, the physician treats a ureteral stricture by balloon dilation, laser, electrocautery, or incision through a cystourethroscope. Under direct vision, the physician passes a flexible or rigid cystourethroscope through the urethra into the bladder. A balloon catheter is placed into the ureteral stricture, and the balloon is gently inflated. After approximately five minutes, the balloon is deflated and removed. In laser treatment of a ureteral stricture, probes, in combination with laser fibers, are used to apply laser energy to the stricture.

In electrocautery, heat is applied to eliminate the stricture. The ureteral stricture may be incised alone or in combination with balloon dilation, laser, or electrocautery to open the blocked ureter. CPT code 52341 is reported when a ureteral stricture is treated. CPT code 52342 is reported when a ureteropelvic junction stricture is treated. CPT code 52343 is reported when an intra-renal stricture is treated.

52341 Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision)

52342 with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision)

52343 with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision)

In some exam, the physician treats a ureteral stricture by balloon dilation, laser, electrocautery, or incision through a cystourethroscope and ureteroscope. CPT code 52344 is reported when a ureteral stricture is treated. CPT code 52345 is reported when a ureteropelvic junction stricture is treated. CPT code 52346 is reported when an intra-renal stricture is treated.

52344 Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision)

52345 with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision)

52346 with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision)

Related CPT codes for Cystourethroscopy

52285 – Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone

This procedure is done for the treatment of Femal urethral Syndrome. This disorder is characterized by urinary frequency and pain on urination without the presence of a urinary tract infection or other urinary tract abnormality. During the treatment, the cystoscope is inserted for urethra inspection. The physician may perform therapeutic procedures depending on the cystoscopic findings.

If the meatus is stenosed, a meatotomy may be performed by incising the urethral meatus. A urethral stricture may be dilated using progressively larger sounds, a filiform and progressively larger followers, or a balloon catheter.

Polyps of the urethra, bladder neck, and/or trigone may be treated using an electrocautery device that is advanced through the urethroscope to the site where the polyps are located. The device is activated and the polyps are destroyed. Alternatively, a laser or cryoprobe may be used to destroy the polyps.

52000 – Cystourethroscopy (separate procedure)

52001 – Cystourethroscopy with irrigation and evacuation of multiple obstructing clots

52005 – Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service

52007 – Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis

52010 – Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service

52204 – Cystourethroscopy, with biopsy(s)

52214 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands

52224 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy

In this exam, physician examines the urinary collecting system with a cystourethroscope passed through the urethra and bladder, and removes tumors of the bladder by electric current (fulguration) or excision. The physician passes an instrument through the endoscope to destroy or remove tumors of the bladder by electric current (fulguration) or excision. The physician may also use liquid nitrogen or carbon dioxide (cryosurgery) or lasers to destroy lesions. The physician removes the instruments and cystourethroscope. For small tumor(s) that are 0.5 up to 2 cm in size, CPT code 52234 is reported. For medium bladder tumor(s) that are 2 to 5 cm in size, CPT code 52235 is reported. For large tumor(s) that are larger than 5 cm, CPT code 52240 is reported.

52234 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)

52235 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

52240 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)

52250 – Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration

52260 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia

52265 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia

52270 – Cystourethroscopy, with internal urethrotomy; female

52275 – Cystourethroscopy, with internal urethrotomy; male

52276 – Cystourethroscopy with direct vision internal urethrotomy

52277 – Cystourethroscopy, with resection of external sphincter (sphincterotomy)

52281 – Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female

52282 – Cystourethroscopy, with insertion of permanent urethral stent

52283 – Cystourethroscopy, with steroid injection into stricture

52285 – Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone

52290 – Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral

52300 – Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral

52301 – Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral

52305 – Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple

52310 – Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

52315 – Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated

52317 – Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm)

52318 – Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)

52320 – Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus

52325 – Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique)

52327 – Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material

52330 – Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus

52332 – Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

52334 – Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde