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CPT® Code 52301 refers to the procedure known as cystourethroscopy with resection or fulguration of ectopic ureterocele(s), which can be performed unilaterally or bilaterally. An ectopic ureterocele is a pathological condition characterized by a saccular outpouching of the distal ureter that protrudes into the urinary bladder, but unlike an orthotopic ureterocele, its orifice is located in an abnormal position, often at the bladder neck or within the urethra. The procedure involves the use of a cystoscope, which is a specialized instrument that allows for direct visualization of the bladder and ureteral orifices. During the procedure, the urethral orifice is first cleansed with an antiseptic solution to minimize the risk of infection. A rigid or flexible cystoscope is then introduced through the urethra into the bladder, and sterile saline may be instilled to enhance the visibility of the bladder wall. The cystoscope allows the physician to inspect the bladder and identify the ectopic ureterocele. If treatment involves fulguration, an electrocautery device is utilized to destroy the ectopic ureterocele. Alternatively, other methods such as laser or cryotherapy may be employed. In cases where resection is indicated, a resectoscope is used to excise the ureterocele, with tissue removal facilitated by irrigation and a cystoscopic evacuation device. Control of any bleeding that may occur during the procedure is achieved through electrocoagulation or laser coagulation. The procedure may be performed on both sides if necessary, and upon completion, the bladder and ureteral orifices are re-evaluated to confirm that the abnormal ureteral tissue has been adequately addressed. This code is specifically designated for ectopic ureteroceles, while a different code, 52300, is used for orthotopic ureteroceles.
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The procedure described by CPT® Code 52301 is indicated for the treatment of ectopic 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 for CPT® Code 52301 involves several critical steps to ensure effective treatment of the ectopic ureterocele. Each step is detailed as follows:
After the completion of the procedure coded under CPT® 52301, patients may require specific post-procedure care to ensure proper recovery and monitor for any complications. Patients are typically observed for any immediate post-operative complications, such as bleeding or infection. Follow-up appointments may be scheduled to assess the success of the procedure and to monitor for any recurrence of symptoms. Patients may also be advised on hydration and urinary habits to promote healing and prevent urinary tract infections. It is essential to provide patients with instructions regarding signs of complications that should prompt immediate medical attention, such as persistent hematuria, fever, or severe pain.
| Short Descr | CYSTOSCOPY AND TREATMENT | Medium Descr | CYSTO W/RESECJ ECTOPIC URETEROCELE UNI/BI | Long Descr | Cystourethroscopy; with resection or fulguration of ectopic 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 |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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) |
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| 1997-01-01 | Added | First appearance in code book in 1997. |
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