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Cystourethroscopy is a diagnostic and therapeutic procedure that allows for the visualization of the interior of the bladder, ureteral orifices, and urethra. This procedure is particularly useful for identifying and addressing issues related to the ureteral openings, which may be restricted or obstructed. During cystourethroscopy, a healthcare professional uses either a rigid or flexible cystoscope, a specialized instrument equipped with a camera and light, which is inserted through the urethra and into the bladder. This enables the physician to inspect the bladder's lining and the ureteral orifices thoroughly. If a ureteral opening is found to be narrowed, a ureteral meatotomy can be performed, which involves making an incision to widen the opening. This incision is made using a retractable blade that is advanced to the ureteral orifice through the cystoscope. The procedure may be performed unilaterally or bilaterally, depending on the patient's specific condition and the findings during the examination. After the incisions are made, they are inspected for any bleeding, which is then controlled before the cystoscope is removed, ensuring that the procedure is completed safely and effectively.
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Indications for performing a cystourethroscopy with ureteral meatotomy include the following:
The procedure of cystourethroscopy with ureteral meatotomy involves several key steps:
Post-procedure care following cystourethroscopy with ureteral meatotomy typically includes monitoring for any immediate complications, such as bleeding or infection. Patients may experience some discomfort or dysuria (painful urination) following the procedure, which is generally temporary. It is important for patients to follow any specific instructions provided by their healthcare provider regarding hydration, activity level, and signs of complications to watch for, such as increased pain, fever, or persistent bleeding. Follow-up appointments may be scheduled to assess recovery and the effectiveness of the procedure.
| Short Descr | CYSTOSCOPY AND TREATMENT | Medium Descr | CYSTOURETHROSCOPY W/URETERAL MEATOTOMY UNI/BI | Long Descr | Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral | 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) | 2 - 150% payment adjustment 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. | 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.) | CR | Catastrophe/disaster related | RT | Right side (used to identify procedures performed on the right side of the body) | 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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