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A bladder diverticulum refers to an abnormal pouch that forms in the wall of the bladder, which can either be present at birth (congenital) or develop later in life (acquired). These diverticula can lead to various complications, including ureteral obstruction, vesicoureteral reflux, recurrent urinary tract infections, and the formation of stones within the bladder. To address these issues, a cystourethroscopy is performed, which is a minimally invasive procedure that allows healthcare professionals to visualize the interior of the bladder, the ureteral openings, and the urethra. During the procedure, the urethral orifice is first cleansed with an antiseptic solution to minimize the risk of infection. A cystoscope, which can be either rigid or flexible, is then carefully introduced through the urethra and into the bladder. To enhance visibility, sterile saline may be instilled into the bladder, allowing for a clearer view of the bladder wall and any diverticula present. The cystourethroscopy enables the physician to inspect the bladder thoroughly, identify the diverticulum, and assess its condition. If treatment is necessary, the procedure may involve either incising the diverticulum or resecting it, depending on the specific circumstances and the number of diverticula present. This procedure is crucial for alleviating symptoms and preventing further complications associated with bladder diverticula.
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The procedure described by CPT® Code 52305 is indicated for the following conditions:
The procedure involves several key steps to ensure effective treatment of bladder diverticula:
After the procedure, patients may require monitoring for any immediate complications, such as bleeding or infection. Post-procedure care typically includes instructions for hydration and monitoring for any signs of urinary tract infection or other complications. Patients may also be advised on activity restrictions and follow-up appointments to assess recovery and ensure that the diverticula have been adequately treated. The expected recovery time can vary based on the extent of the procedure and the patient's overall health.
| Short Descr | CYSTOSCOPY AND TREATMENT | Medium Descr | CYSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT | Long Descr | Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple | 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 | 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 |
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| Pre-1990 | Added | Code added. |
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