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A cystotomy for excision, incision, or repair of a ureterocele is a surgical procedure aimed at addressing a ureterocele, which is a congenital condition characterized by the cystic dilation of the submucosa of the ureter. This dilation typically occurs at the distal end of the ureter, near the junction where the ureter meets the bladder, known as the ureterovesical junction. During the procedure, a midline extraperitoneal abdominal approach is employed to gain access to the bladder. The surgical team carefully divides the rectus and transversalis fascia, creating an incision that extends through the space of Retzius, allowing for the identification of the anterior bladder wall and the vesical neck. Once the bladder dome is incised, the surgeon inspects the bladder wall, including critical areas such as the trigone, ureteral orifices, and bladder neck, to locate the ureterocele. Treatment options for the ureterocele include excision, incision, or repair. Excision involves making a circumferential incision around the ureterocele with electrocautery to remove the dilated submucosal tissue. Incision entails deflating the ureterocele by making a full-thickness incision that starts at the roof and extends to the base of the defect. Repair consists of excising the ureterocele and subsequently repairing any associated defects in the ureteral or bladder wall. This procedure is essential for alleviating symptoms and preventing complications associated with ureteroceles.
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The cystotomy for excision, incision, or repair of a ureterocele is indicated for patients presenting with the following conditions:
The procedure for cystotomy for excision, incision, or repair of a ureterocele involves several critical steps:
Post-procedure care following a cystotomy for excision, incision, or repair of a ureterocele typically includes monitoring for any complications such as infection or bleeding. Patients may be advised to follow up with their healthcare provider to assess recovery and ensure proper healing of the surgical site. Additionally, hydration and urinary function should be monitored to ensure that the obstruction has been adequately addressed. Pain management may also be necessary, and patients should be educated on signs of potential complications that warrant immediate medical attention.
| Short Descr | REPAIR OF URETER LESION | Medium Descr | CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE | Long Descr | Cystotomy for excision, incision, or repair of ureterocele | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; 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 |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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). | 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) |
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| 2011-01-01 | Changed | Medium description changed. |
| Pre-1990 | Added | Code added. |
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