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Official Description

Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 51525 refers to a surgical procedure known as cystotomy for the excision of bladder diverticulum, which can occur as a single or multiple diverticula. A bladder diverticulum is characterized by a protrusion of the bladder's mucosal tissue through the detrusor muscle, leading to an abnormal pouch that can extend into the abdominal cavity. This procedure is performed through a midline extraperitoneal abdominal approach, allowing the surgeon to gain access to the bladder by carefully dividing the rectus and transversalis fascia and making an incision through the space of Retzius. Once the anterior bladder wall and vesical neck are identified, the bladder dome is incised to facilitate inspection of the bladder wall, including critical areas such as the trigone, ureteral orifices, and bladder neck. The excision of the diverticulum involves either pulling the diverticulum into the bladder for intravesical excision or addressing any adhesions that may prevent this maneuver. The procedure is completed with the repair of the bladder wall defect, ensuring the integrity of the bladder is restored. This code is specifically designated for cases where the excision of bladder diverticula is performed as a separate procedure, distinguishing it from other bladder surgeries that may involve different techniques or indications.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 51525 is indicated for the excision of bladder diverticula, which may present as single or multiple pouches. The following conditions may warrant this surgical intervention:

  • Bladder Diverticulum A protrusion of the bladder's mucosal tissue through the detrusor muscle, which can lead to complications such as urinary retention, recurrent urinary tract infections, or bladder obstruction.
  • Symptoms of Urinary Tract Issues Patients may experience symptoms such as frequent urination, pain during urination, or difficulty emptying the bladder, which can be associated with the presence of diverticula.
  • Complications from Existing Diverticula The presence of diverticula may lead to complications that necessitate surgical intervention, including inflammation, infection, or the formation of stones within the diverticulum.

2. Procedure

The procedure for CPT® Code 51525 involves several critical steps to ensure the successful excision of bladder diverticula:

  • Step 1: Surgical Access The surgeon begins by making a midline extraperitoneal abdominal incision to access the bladder. This approach allows for optimal visualization and manipulation of the bladder while minimizing trauma to surrounding structures.
  • Step 2: Dissection The rectus and transversalis fascia are carefully divided, and the incision is extended through the space of Retzius. This dissection is crucial for exposing the anterior bladder wall and vesical neck, which are essential landmarks for the procedure.
  • Step 3: Bladder Inspection Once the bladder is exposed, the bladder dome is incised. The surgeon inspects the bladder wall, focusing on the trigone, ureteral orifices, and bladder neck to assess the extent of the diverticula and any associated abnormalities.
  • Step 4: Excision of Diverticula The excision of one or more bladder diverticula is performed. If the diverticulum can be pulled into the bladder, intravesical excision is conducted by applying tension to the everted diverticulum and excising it at its base using electrocautery. If adhesions prevent this maneuver, the mucosa around the diverticular orifice is divided, and adhesions are lysed to facilitate the removal of the diverticulum.
  • Step 5: Repair of Bladder Wall After the diverticulum is excised, the defect in the bladder wall is meticulously repaired to restore the bladder's integrity and function.
  • Step 6: Closure The bladder incision is closed, followed by the closure of the abdominal incision in layers to ensure proper healing and minimize the risk of complications.

3. Post-Procedure

Post-procedure care following the excision of bladder diverticula involves monitoring for any signs of complications such as infection, bleeding, or urinary retention. Patients may require a catheter for a period to facilitate bladder drainage and healing. Follow-up appointments are essential to assess recovery and ensure that the bladder is functioning properly. Patients are typically advised on activity restrictions and signs to watch for that may indicate complications, ensuring a smooth recovery process.

Short Descr REMOVAL OF BLADDER LESION
Medium Descr CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE
Long Descr Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure)
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) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Inpatient Procedures, not paid under OPPS
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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.)
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.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AG Primary physician
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)
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
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Notes
2011-01-01 Changed Medium description changed.
Pre-1990 Added Code added.
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