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Cystourethroscopy is a medical procedure that allows healthcare professionals to visualize the interior of the bladder and urethra. This is achieved through the insertion of a cystoscope, which can be either rigid or flexible, into the urethra. Prior to the procedure, the urethra is typically cleansed with an antiseptic solution to minimize the risk of infection. During the cystourethroscopy, the bladder may be filled with sterile saline, enhancing the visibility of the bladder wall for better examination. Following the inspection of the bladder, the procedure may involve catheterization of the ureters. This process includes the introduction of a guidewire through the cystoscope, which is then advanced into the first ureter and further into the renal pelvis. A catheter is subsequently advanced over the guidewire to reach the renal pelvis. At this stage, the ureter may be irrigated with normal saline, or a diagnostic or therapeutic solution may be instilled. Additionally, contrast material can be injected to facilitate ureteropyelography, which is a separate reportable service. The procedure can be performed on both ureters if necessary. In the context of CPT® Code 52007, the procedure includes the collection of tissue samples from the ureters or renal pelvis using a nylon or steel brush, which is an essential step for diagnostic purposes.
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The procedure described by CPT® Code 52007 is indicated for various clinical scenarios where visualization and assessment of the bladder and ureters are necessary. The following conditions may warrant the performance of this procedure:
The procedure involves several critical steps to ensure effective visualization and intervention. The following outlines the procedural steps associated with CPT® Code 52007:
After the completion of the cystourethroscopy with ureteral catheterization and brush biopsy, patients are typically monitored for any adverse reactions or complications. Common post-procedure care may include advising the patient to drink plenty of fluids to help flush out the urinary system. Patients may experience some discomfort, such as mild pain or burning during urination, which is generally temporary. It is important to provide instructions regarding signs of complications, such as fever, excessive bleeding, or severe pain, which should prompt immediate medical attention. Follow-up appointments may be scheduled to discuss biopsy results and any further management required based on the findings of the procedure.
| Short Descr | CYSTO URTRL CATHJ BRUSH BX | Medium Descr | CYSTO W/URTRL CATHJ BRUSH BX URTR&/RENAL PELVIS | Long Descr | Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | 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. | Endoscopic Base Code | 52000 Cystourethroscopy (separate 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) | P8E - Endoscopy - cystoscopy | MUE | 1 | CCS Clinical Classification | 100 - Endoscopy and endoscopic biopsy of the 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. | 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). | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | CR | Catastrophe/disaster related | 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | 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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| 2025-01-01 | Changed | Short Description changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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