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Cystourethroscopy with mechanical dilation and therapeutic drug delivery by drug-coated balloon catheter is a specialized medical procedure performed to address male urethral stricture or stenosis. Urethral stricture refers to the narrowing of the urethral lumen, which can occur due to various factors including injury, inflammation, infection, previous surgical interventions, catheterization, instrumentation, treatment for prostate cancer, or congenital and idiopathic causes. This procedure is essential for restoring normal urinary flow and alleviating symptoms associated with urethral obstruction. Prior to the intervention, a retrograde urethrogram is conducted to measure the length of the stricture, ensuring that the balloon can be accurately positioned with healthy urethra margins on either side, which is crucial for minimizing the risk of recurrence. The procedure involves the use of a cystourethroscope, which is inserted through the urethra into the bladder, allowing for direct visualization and assessment of the urethra and bladder. Fluoroscopy is utilized during the procedure to enhance imaging and facilitate the capture of diagnostic images. The mechanical dilation is achieved by gradually inflating a balloon catheter, which increases the diameter of the urethral lumen. Following this dilation, a drug-coated balloon catheter is introduced to deliver therapeutic medication directly to the affected area, with the balloon remaining inflated for a minimum of five minutes to ensure effective drug application. This comprehensive approach aims to treat the stricture effectively while minimizing the likelihood of future complications.
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The procedure is indicated for the treatment of male urethral stricture or stenosis, which may arise from various underlying conditions. The specific indications include:
The procedure involves several critical steps to ensure effective treatment of the urethral stricture. These steps include:
Post-procedure care involves monitoring the patient for any immediate complications and ensuring proper recovery. Patients may experience some discomfort or urinary symptoms following the procedure, which should be managed appropriately. It is important to provide instructions regarding hydration, potential side effects, and signs of complications that should prompt immediate medical attention. Follow-up appointments may be necessary to assess the effectiveness of the treatment and to monitor for any recurrence of stricture.
| Short Descr | CYSTO RX BALO CATH URTL STRX | Medium Descr | CYSTO W/DILAT RX BALO CATH URTL STRIX/STEN MALE | Long Descr | Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed | 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 | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
| 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | LT | Left side (used to identify procedures performed on the left side of the body) | SG | Ambulatory surgical center (asc) facility service | 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 | 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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| 2024-01-01 | Added | Code Added. |
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