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CPT® Code 52275 refers to a medical procedure known as cystourethroscopy with internal urethrotomy specifically performed on males. This procedure is primarily indicated for the treatment of internal urethral stricture, a condition where the urethra becomes narrowed, leading to difficulties in urination. The process begins with cystourethroscopy, which involves the use of a cystoscope—a specialized instrument that allows visualization of the bladder and urethra. This visualization is crucial for identifying the precise location and extent of the urethral stricture. Prior to the procedure, the urethral orifice is cleansed with an antiseptic solution to minimize the risk of infection. A rigid or flexible cystoscope is then carefully introduced through the urethra into the bladder, allowing the physician to inspect the bladder and examine the ureteral orifices. Once the area of stricture is located, a cold knife incision is made at the 12 o'clock position, or multiple radial incisions may be performed at the site of the stricture. If there are multiple stricture sites, the procedure is repeated until all narrowed areas are adequately incised. Following the incisions, the urethra is re-examined using the cystoscope to ensure that the procedure has been effective. Finally, a Foley catheter is placed through the urethra into the bladder to help maintain the diameter of the treated areas, facilitating proper healing and function. It is important to note that different codes are used for similar procedures in females and for direct vision urethrotomy, which involves a different technique for visualizing and treating the stricture.
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The procedure described by CPT® Code 52275 is indicated for the treatment of internal urethral stricture in males. This condition can lead to various urinary symptoms, including difficulty urinating, urinary retention, and recurrent urinary tract infections. The internal urethral stricture may result from trauma, infection, or previous surgical procedures, necessitating intervention to restore normal urinary function.
The procedure begins with the cleansing of the urethral orifice using an antiseptic solution to reduce the risk of infection. Following this, a rigid or flexible cystoscope is introduced through the urethra into the bladder. This instrument allows the physician to visualize the interior of the bladder and the urethra, facilitating the identification of the ureteral orifices. Once the bladder is inspected, the cystoscope is slowly withdrawn to locate the area of stricture within the urethra. At this point, a cold knife incision is made at the 12 o'clock position of the stricture, or multiple radial incisions may be performed at the site of the narrowing. If the physician identifies multiple areas of stricture, the incision procedure is repeated for each affected site until all narrowed portions of the urethra have been adequately incised. After the incisions are made, the urethra is re-examined using the cystoscope to ensure that the stricture has been effectively treated. Finally, the cystoscope is removed, and a Foley catheter is placed through the urethra into the bladder. This catheter serves to maintain the diameter of the treated areas, promoting healing and preventing re-narrowing of the urethra.
After the completion of the procedure, patients are typically monitored for any immediate complications. The placement of the Foley catheter is crucial as it helps maintain the diameter of the treated urethra and facilitates urine drainage. Patients may experience some discomfort or urinary urgency following the procedure, which is generally expected. The Foley catheter is usually kept in place for a specified duration, as determined by the physician, to ensure proper healing of the incised areas. Follow-up appointments are essential to assess the success of the procedure and to monitor for any recurrence of stricture. Patients should be advised on signs of potential complications, such as increased pain, bleeding, or signs of infection, and instructed to seek medical attention if these occur.
| Short Descr | CYSTOSCOPY & REVISE URETHRA | Medium Descr | CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE | Long Descr | Cystourethroscopy, with internal urethrotomy; male | 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) | 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. | 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 | 109 - Procedures on the urethra |
| 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SG | Ambulatory surgical center (asc) facility service | 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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