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CPT® Code 52355 refers to a specific medical procedure known as cystourethroscopy with ureteroscopy and/or pyeloscopy, which includes the resection of a tumor located in the ureter or renal pelvis. This procedure is performed to diagnose and treat tumors or abnormal tissues found in the urinary tract. The process begins with the cleansing of the urethra using an antiseptic solution to minimize the risk of infection. A cystoscope, which can be either rigid or flexible, is then inserted through the urethra into the bladder. To enhance visibility, sterile saline may be introduced into the bladder, allowing for a clearer view of the bladder wall. Once the bladder is inspected, the ureters are catheterized to facilitate access to the urinary system. A guidewire is introduced through the cystoscope and advanced into the ureter or renal pelvis, guiding the physician to the site of the lesion or abnormal tissue. After the cystoscope is removed, a ureteroscope is advanced over the guidewire to the tumor site. This procedure may involve obtaining tissue samples for biopsy or directly treating the tumor using various techniques such as electrocautery, laser, or cryotherapy. In the case of CPT® Code 52355, the focus is on the resection of the tumor, which involves the use of a resectoscope to excise the tumor, followed by the removal of the tumor using irrigation and an endoscopic evacuation device. Throughout the procedure, measures are taken to control any bleeding that may occur, ensuring patient safety and effective treatment of the tumor.
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The procedure associated with CPT® Code 52355 is indicated for the following conditions:
The procedure begins with the cleansing of the urethra 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. After inspecting the bladder, the ureters are catheterized to facilitate access to the urinary system. A guidewire is then introduced through the cystoscope and advanced into the ureter or renal pelvis, guiding the physician to the site of the lesion or abnormal tissue. Once the cystoscope is removed, a ureteroscope is advanced over the guidewire to the tumor site. In cases where a biopsy is needed, biopsy forceps are introduced through the ureteroscope to obtain tissue samples. After the biopsy, the renal pelvis and/or ureter are re-inspected, and any bleeding is controlled. Alternatively, an electrocautery device, laser, or cryoprobe may be advanced through the ureteroscope to the site of the lesion, where it is activated to destroy the abnormal tissue through fulguration. For the specific procedure coded as CPT® Code 52355, the renal pelvis and/or ureteral tumor is located, and a resectoscope is advanced to the tumor site for resection. The tumor is then removed using irrigation and an endoscopic evacuation device. Throughout the procedure, bleeding is controlled as necessary using electrocoagulation or laser coagulation. After the biopsy, fulguration, or tumor resection, a catheter may be advanced over the guidewire to the renal pelvis, and both the ureter and renal pelvis may be irrigated. Additionally, diagnostic or therapeutic solutions may be instilled through the catheter, and the ureteroscope may be advanced into the renal pelvis for further examination as it is slowly withdrawn.
Post-procedure care following the cystourethroscopy with ureteroscopy and/or pyeloscopy involves monitoring the patient for any complications such as bleeding or infection. Patients may be advised to drink plenty of fluids to help flush the urinary system. Depending on the extent of the procedure and the patient's condition, a catheter may be left in place temporarily to facilitate urine drainage and allow for healing. Follow-up appointments may be scheduled to assess recovery and discuss biopsy results if tissue samples were taken. It is important for patients to report any unusual symptoms, such as severe pain, fever, or changes in urination, to their healthcare provider promptly.
| Short Descr | CYSTOURETERO W/EXCISE TUMOR | Medium Descr | CYSTO/PYELOSCOPY RESCJ PELVIC TUMOR | Long Descr | Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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 | 52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic | 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 | 112 - Other OR therapeutic procedures of urinary tract |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 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. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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.) | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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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| 2003-01-01 | Changed | Code description changed. |
| 2001-01-01 | Added | First appearance in code book in 2001. |
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