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CPT® Code 52285 refers to a cystourethroscopy procedure specifically designed for the treatment of female urethral syndrome. This syndrome is characterized by symptoms such as urinary frequency and pain during urination, which occur in the absence of a urinary tract infection or any identifiable urinary tract abnormalities. The procedure begins with the cleansing of the urethral orifice using an antiseptic solution to minimize the risk of infection. A rigid or flexible cystoscope, which is a thin tube equipped with a camera and light, is then carefully introduced through the urethra into the bladder. To enhance visualization of the bladder wall, sterile saline may be instilled into the bladder. During the cystoscopy, the physician inspects the bladder and identifies the ureteral orifices for examination. Following this, the cystoscope is gradually withdrawn to allow for inspection of the urethra. Depending on the findings observed during the cystoscopy, the physician may perform various therapeutic interventions. These may include urethral meatotomy or dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and/or fulguration of any polyps found in the urethra, bladder neck, or trigone area. If a stenosis (narrowing) of the meatus is detected, a meatotomy may be performed, which involves making an incision in the urethral meatus to widen it. In cases of urethral stricture, dilation techniques may be employed using progressively larger sounds, filiforms, and followers, or a balloon catheter to restore normal urethral diameter. Polyps located in the urethra, bladder neck, or trigone can be treated using an electrocautery device, which is advanced through the urethroscope to the site of the polyps. The device is activated to destroy the polyps, although alternative methods such as laser or cryoprobe may also be utilized for this purpose. Additionally, any fibrotic adhesions at the urethrovaginal septum may be severed as necessary, and transurethral relaxing incisions can be made at the bladder neck if indicated. Upon completion of the procedure, the bladder trigone, neck, and urethra are re-inspected with the cystoscope to ensure that any bleeding is controlled before the cystoscope is removed.
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The procedure described by CPT® Code 52285 is indicated for the treatment of female urethral syndrome, which is characterized by the following symptoms and conditions:
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. To improve visualization of the bladder wall, sterile saline may be instilled into the bladder. The physician then inspects the bladder and identifies the ureteral orifices for examination. After this initial inspection, the cystoscope is slowly withdrawn to allow for a thorough examination of the urethra.
Upon completion of the procedure, the bladder trigone, neck, and urethra are re-inspected with the cystoscope to ensure that any bleeding is controlled. The cystoscope is then carefully removed. Post-procedure care may include monitoring for any signs of complications, such as bleeding or infection, and providing the patient with instructions for recovery. Patients may be advised to increase fluid intake and to report any unusual symptoms to their healthcare provider. Follow-up appointments may be scheduled to assess the effectiveness of the procedure and to monitor the patient's recovery.
| Short Descr | CYSTOSCOPY AND TREATMENT | Medium Descr | CYSTOURETHROSCOPY TX FEMALE URETHRAL SYNDROME | Long Descr | Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone | 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). | 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. | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition |
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| 2011-01-01 | Changed | Medium description changed. |
| Pre-1990 | Added | Code added. |
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