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CPT® Code 51065 refers to a surgical procedure known as cystotomy, which involves making an incision in the urinary bladder to facilitate the extraction of a ureteral calculus, or kidney stone. This procedure is typically indicated when a patient has a stone that is obstructing the urinary tract and cannot be removed through less invasive methods. The term 'cystotomy' specifically denotes the surgical opening of the bladder, allowing access to the ureter where the calculus is located. During the procedure, a skin incision is made in the lower abdomen, and various layers of tissue are carefully dissected to reach the bladder. The bladder wall is then incised to allow for the removal of the stone, which may be accomplished through a basket extraction technique or by using lithotripsy methods such as ultrasonic or electrohydraulic fragmentation. This procedure is essential for relieving obstruction and preventing further complications associated with ureteral stones, such as infection or kidney damage.
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The procedure described by CPT® Code 51065 is indicated for the following conditions:
The procedure begins with a skin incision made in the lower abdomen, specifically over the urinary bladder. This incision allows access to the underlying tissues, which are carefully dissected down to the anterior rectus muscle sheath. The rectus abdominus and pyramidalis muscles are then separated and retracted to provide a clear view of the peritoneum, which is subsequently reflected. Once the urinary bladder is exposed, a precise incision is made in the bladder wall to perform the cystotomy, which is necessary for the basket extraction and/or fragmentation of the ureteral calculus.
To facilitate the procedure, two stay sutures are placed in the bladder wall, positioned laterally to the planned incision site. These sutures are pulled to tent the bladder, creating a stable working area. A stab incision is then made between the stay sutures in the tented portion of the bladder, which is carefully enlarged until the ureteral orifice becomes visible. At this point, a basket extraction device is advanced through the bladder and into the ureter, allowing the surgeon to capture the calculus for removal.
If necessary, lithotripsy may be performed using either ultrasonic or electrohydraulic devices to fragment the ureteral calculus prior to, or instead of, the basket extraction. This step is crucial for ensuring that all stone fragments can be effectively removed. Once the calculus and any fragments have been successfully extracted, the bladder incision is closed, followed by the closure of the abdominal incision in layers to ensure proper healing.
After the completion of the cystotomy and stone extraction, post-procedure care is essential for patient recovery. Patients are typically monitored for any signs of complications, such as infection or bleeding. Pain management is also an important aspect of post-operative care, as patients may experience discomfort following the incision and manipulation of the bladder. Follow-up appointments are necessary to assess healing and ensure that no residual stones remain in the urinary tract. Additionally, patients may be advised on hydration and dietary modifications to prevent future occurrences of ureteral calculi.
| Short Descr | REMOVE URETER CALCULUS | Medium Descr | CYSTOTOMY W/CALCULUS BASKET XTRJ&/FRAGMENTATIO | Long Descr | Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 0 - 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 | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 112 - Other OR therapeutic procedures of urinary tract |
| 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. | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 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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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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