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This procedure, known as cystourethroscopy with resection or fulguration of orthotopic ureterocele(s), involves the endoscopic examination and treatment of ureteroceles, which are abnormal dilations of the ureter that can protrude into the bladder. An orthotopic ureterocele is characterized by its orifice being located in the normal anatomical position within the bladder, as opposed to an ectopic ureterocele, which has its orifice in an abnormal location, such as the bladder neck or urethra. The cystourethroscopy allows for direct visualization of the bladder and ureteral openings, facilitating the identification and treatment of the ureterocele. During the procedure, a cystoscope—either rigid or flexible—is inserted through the urethra into the bladder, often with the bladder filled with sterile saline to enhance visibility. The procedure may involve either fulguration, where an electrocautery device is used to destroy the ureterocele, or resection, where the abnormal tissue is surgically removed. The choice of technique depends on the specific characteristics of the ureterocele and the clinical judgment of the physician. This procedure is critical for addressing urinary obstruction and preventing potential complications associated with ureteroceles.
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The procedure is indicated for the treatment of orthotopic ureteroceles, which may present with various symptoms or conditions that necessitate intervention. The following are the explicitly provided indications for performing this procedure:
The procedure involves several key steps to ensure effective treatment of the ureterocele. The following procedural steps are performed:
After the procedure, patients may require monitoring for any immediate complications, such as bleeding or infection. It is essential to assess the patient's recovery and ensure that they are stable before discharge. Patients may experience some discomfort or urinary symptoms post-procedure, which should be managed appropriately. Follow-up appointments are typically scheduled to evaluate the success of the procedure and to monitor for any recurrence of symptoms or complications. Additional imaging or diagnostic tests may be performed as needed to ensure the complete resolution of the ureterocele and to assess urinary function.
| Short Descr | CYSTOSCOPY AND TREATMENT | Medium Descr | CYSTO W/RESCJ/FULG ORTHOPIC URETEROCELE UNI/BI | Long Descr | Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), 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) | 0 - 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 | 101 - Transurethral excision, drainage, or removal urinary obstruction |
| 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. | 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. | 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service |
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