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Cystourethroscopy is a minimally invasive procedure that involves the examination of the bladder and urethra using a specialized instrument called a cystourethroscope. This procedure is particularly indicated for patients suffering from urethral stricture or stenosis, conditions characterized by the narrowing of the urethral lumen. Such narrowing can result from various factors, including injury, inflammation, infection, previous surgical interventions, catheterization, instrumentation, treatment for prostate cancer, or may even be congenital or idiopathic in nature. During the procedure, the patient is positioned in a dorsolithotomy position, which facilitates access to the urethra. The cystourethroscope is carefully inserted through the urethra and advanced into the bladder, allowing for a thorough inspection of the bladder's interior. Fluoroscopy may be utilized during this process to enhance visualization and capture images for further analysis. After inspecting the bladder, the cystourethroscope is withdrawn to examine the entire length of the urethra. To address the stricture or stenosis, a thin wire is introduced into the urethra, followed by the insertion of progressively larger dilators that mechanically widen the urethral lumen. Once dilation is achieved, the cystourethroscope is reinserted to identify the specific area requiring treatment. Therapeutic drug delivery is then performed, typically involving the injection of an anti-proliferative or anti-scar medication through the working port of the cystourethroscope. This injection aims to reduce the likelihood of scar tissue formation and promote healing. The procedure concludes with the removal of the cystourethroscope, ensuring that the targeted therapeutic intervention has been successfully administered.
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The procedure is indicated for the following conditions:
The procedure consists of several key steps that ensure effective diagnosis and treatment of urethral stricture or stenosis:
Post-procedure care involves monitoring the patient for any immediate complications and ensuring proper recovery. Patients may experience some discomfort or urinary symptoms following the procedure, which should be managed appropriately. Follow-up appointments may be necessary to assess the effectiveness of the dilation and drug delivery, as well as to monitor for any recurrence of stricture or stenosis. Patients should be advised on signs of complications, such as increased pain, bleeding, or difficulty urinating, and instructed to seek medical attention if these occur.
| Short Descr | CYSTO F/URTL STRIX/STENOSIS | Medium Descr | CYSTO W/DIL & URTL RX DEL F/URTL STRIX/STENOSIS | Long Descr | Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed | Status Code | Carriers Price the Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Berenson-Eggers TOS (BETOS) | none | MUE | Not applicable/unspecified. |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AG | Primary physician | GW | Service not related to the hospice patient's terminal condition | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2023-12-31 | Deleted | Code Deleted, see 52284. |
| 2022-11-10 | Note | Code originally deleted in printed 2023 CPT codebook but later revised per CPT Errata & Technical Corrections. It is now scheduled to sunset on January 2028. |
| 2018-01-01 | Added | Code Added. |
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