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Urology Coding Expert with Medycoding

What is UroLift?

UroLift is a minimally invasive procedure used to treat benign prostatic hyperplasia (BPH), a condition in which the prostate gland enlarges and blocks the flow of urine.

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How Does UroLift Work?

  • Small permanent implants are placed in the prostate to lift and hold the enlarged tissue away from the urethra.

  • This opens the urethra, allowing urine to flow freely.

  • Unlike other treatments, UroLift does not involve cutting, heating, or removing tissue, reducing the risk of side effects.

52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant

 

+52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)

 

(To report removal of implant[s], use 52310)


52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

Laser therapy is one of the advanced treatments for Benign Prostatic Hyperplasia (BPH), a condition where the prostate gland enlarges, leading to urinary difficulties. 

1. Holmium Laser Enucleation of the Prostate (HoLEP)

  • Procedure: This method involves the use of a high-powered laser (Holmium laser) to remove the excess prostate tissue that is obstructing the urinary flow. The laser energy is used to vaporize or enucleate the tissue, and then it is removed from the prostate.
     

2. Laser Vaporization of the Prostate (PVP)

  • Procedure: This is the most common laser therapy for BPH and is performed using a KTP (Potassium Titanyl Phosphate) laser. It vaporizes the excess prostate tissue, which shrinks the prostate and relieves obstruction..
     

3. PhotoSelectively Vaporization of the Prostate (PVP)

  • Procedure: This laser treatment uses a green laser to target the prostate tissue. It vaporizes the obstructing tissue and shrinks the prostate.
     

4. Thulium Laser Enucleation of the Prostate (ThuLEP)

Procedure: The Thulium laser is used for enucleation (removal) of prostate tissue, similar to HoLEP. It allows for precise cutting and vaporization of the tissue.

52647 Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed)

  1. Cystoscope Insertion.

  2. Resectoscope insertion.

  3.  A laser–emitting fiber optic probe device is inserted.

  4. The heat energy conducted through the probe coagulates the target tissue.

  5. During this procedure the physician can perform a vasectomy, meatotomy, and internal urethrotomy.

 

What is Coagulation of Prostate ?

In procedures such as laser therapy or radiofrequency ablation, heat is used to coagulate (or "burn") prostate tissue.

52648 Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

  1. Cystoscope Insertion.

  2. Resectoscope insertion.

  3. The target tissue is fired with the laser

  4. During this procedure the physician can perform a vasectomy, meatotomy, and internal urethrotomy.

52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

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This procedure represent the Holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation

  1. Cystoscope Insertion.

  2. Resectoscope insertion.

  3.  A laser–emitting fiber optic probe device is inserted.

  4. A morcellator is used to cut prostate adenoma into smaller pieces (morcellation).

  5. During this procedure the physician can perform a vasectomy, meatotomy, and internal urethrotomy.

 

What is Enucleation ?

Enucleation refers to the surgical removal or extraction of an organ or mass, typically without cutting into the surrounding tissue. The term comes from the Latin word enucleare, meaning "to remove the kernel" or "to remove the core."

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What is Morcellation ?

Fragmentation of larger tissues into smaller pieces for easy removal.

What is TURP ?. 

TURP stands for Transurethral Resection of the Prostate, which is a common surgical procedure used to treat Benign Prostatic Hyperplasia (BPH).

Procedure: TURP is performed by removing parts of the enlarged prostate tissue using a specialized instrument called a resectoscope. This device is inserted through the urethra (the tube that carries urine from the bladder) to access the prostate. The surgeon uses the resectoscope to trim or cut away the prostate tissue blocking the urethra, thereby improving the flow of urine.

Electrosurgical resection

52601 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)

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  1. Cystourethroscope is Inserted.

  2. May dilate the urethra by making incision known as meatotomy

  3. Using a resectoscope loop, resection is performed

  4. During this procedure the physician can perform a vasectomy, meatotomy, and internal urethrotomy.

 

How many lobes are there in prostate ?

There are five lobes in the prostate

  • Anterior

  • Posterior

  • Lateral (Right and Left)

  • Medial 

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52630 Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)

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  1. Cystourethroscope is Inserted.

  2. Excises the residual and obstructive prostate tissue by blunt and sharp dissection.

0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)

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Using real–time ultrasound guidance, the provider performs prostate ablation using preprogrammed robotically guided high–velocity jet of saline delivered through a cystoscope placed through the urethra to destroy the prostate.

TURBT stands for Transurethral Resection of Bladder Tumor, a minimally invasive surgical procedure used to diagnose and treat bladder cancer.

TURBT (Transurethral Resection of Bladder Tumor)

  1. 52250: With insertion of Radioactive Substance

  2. 52224: Minor (less than 0.5 cm)

  3. 52234: Small (0.5 to 2.0 cm)

  4. 52235: Medium (2.0 to 5.0 cm)

  5. 52240: Large  (2.0 to 5.0 cm)

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52224 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy

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52234 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)

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52235 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

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52240 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)

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52250 Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration

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Fulguration: Surgical treatment using high–frequency electric currents to produce heat in a part of the body, to increase blood flow, relieve pain, destroy unhealthy tissue, or cause bleeding vessels to clot.

Transurethral Resection of the Bladder Neck (TURBN) is a surgical procedure used to treat bladder outlet obstruction caused by bladder neck contracture (BNC) or other conditions that lead to the narrowing of the bladder neck (the area where the bladder meets the urethra).

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 (Transurethral Resection of Bladder Neck Contracture )

  1. 52640: Postoperative bladder neck Contracture

  2. 52500: Transurethra resection of bladder neck (Separate Procedure)

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52640 Transurethral resection; of postoperative bladder neck contracture

​Postoperative bladder neck contracture (BNC) is generally due to prostatectomy surgery. The surgical procedure involves the removal of these contracture performed under an endoscope.​​

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52500 Transurethral resection of bladder neck (separate procedure)

In this procedure, the provider passes a cystourethroscope through the urethra and examines the interior of the urethra, then advances it further and excises tissue from the bladder neck to treat a urinary obstruction.​

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Vasectomy 

A vasectomy is a surgical procedure used as a method of permanent contraception for men. It involves the cutting or blocking of the vas deferens, the tubes that carry sperm from the testes to the urethra.

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55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)

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What is Penile Prosthetic Implant

A penile prosthesis is an artificial device that is implanted into the penis to allow a man to achieve and maintain an erection.

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Types of Penile Prosthetic Implants

There are three main types of penile implants:

  1. Inflatable Penile Prosthesis (IPP)

    • The most common type of penile implant used today.

    • It consists of three parts:

      • Cylinders implanted into the penis.

      • A pump placed in the scrotum.

      • A reservoir that holds saline solution, usually placed in the abdomen.

    • To achieve an erection, the man presses the pump in the scrotum, which causes saline to flow into the cylinders in the penis, inflating them and producing an erection.

    • To deflate the implant, the pump is pressed again, and the saline flows back into the reservoir, returning the penis to a flaccid state.

  2. Semi-Rigid or Malleable Penile Prosthesis

    • This type consists of bendable rods implanted into the penis.

    • These rods allow the penis to be manually adjusted to the desired position (up for sexual activity, down for concealment).

    • It is simpler than the inflatable model but lacks the natural appearance and rigidity that an inflatable prosthesis provides.

  3. Self-Contained or One-Piece Implant

    • This is a less common type that combines both the inflatable mechanism and the pump within a single device.

    • The entire unit is inserted into the penis, simplifying the procedure.

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Internal Prosthesis of Penis

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Insertion

  1. 54001: Insertion of Penile Prosthesis ; Inflatable (Self-Contained)

  2. 54400  Insertion of Non Inflatable (Semi-rigid)

  3. 54405:  Insertion of Inflatable, Multi-component (Includes placement of pump, cylinders and/or reservoir)

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Removal and replacement

  1. 54416: Removal and replacement of Penile Prosthesis ; Inflatable or Non inflatable

  2. 54417: Removal and replacement of Penile Prosthesis ; Inflatable or Non inflatable through infected field including irrigation and debridement of infected tissue.

  3. 54410 : Removal and replacement of all component of a multi-component, inflatable penile prosthesis

  4. 54411 : Removal and replacemnt of all component of a multi-component, inflatable penile prosthesis through infected field including irrigation and debridement of infected tissue.

Note: (For reduced services, report 54411 with modifier 52)

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Removal

  1. 54415: Removal of non-inflatable or inflatable penile prosthesis, without replacement of prosthesis.

  2. 54406: Removal of all components of multicompnent, inflatable penile prosthesis 

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Repair

  1. 54408: Repair of components of a multi-component, inflatable penile prosthesis

  2. 55899: Repair of Penile Prosthesis ; Inflatable or Non inflatable

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Note: When the provider removes one type of prosthesis and replaces it with a different type of prosthesis, search and chose from the procedure codes (54410, 54411, 54416, and 54417) representing penile prosthesis insertion and removal that cover a wide range of penile implant procedures. To choose the proper code for the removal and replacement, you should follow one rule. Base your coding on what type of prosthesis the provider inserts, not on the type he removes, because the insertion portion of the procedure is the most effort and time consuming.

ESWL stands for Extracorporeal Shock Wave Lithotripsy. It is a non-invasive medical procedure used to treat kidney stones or urinary tract stones. ESWL uses shock waves to break down stones in the kidneys or ureter into smaller pieces, allowing them to be passed more easily through the urinary system.

50590 Lithotripsy, extracorporeal shock wave

​Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to destroy calculus (kidney stones) in the kidneys and ureters. ​​​

An artificial urinary sphincter (AUS) is a medical device used to treat urinary incontinence in individuals who have lost control over their bladder. 

The artificial urinary sphincter is made up of three main components:

  • Cuff: The cuff is placed around the urethra. It inflates to squeeze the urethra shut, preventing urine leakage. When inflated, it works to block urine flow in the same way a healthy urinary sphincter would.

  • Pump: The pump is implanted in the scrotum (in men) or labia (in women). It is used by the patient to control the opening and closing of the cuff. When the patient wants to urinate, they press the pump, which deflates the cuff and allows urine to flow out.

  • Reservoir: The reservoir is typically implanted in the abdomen or the pelvic area. It holds a saline solution that is used to inflate and deflate the cuff. The pump, when pressed, moves the saline fluid from the reservoir into the cuff, inflating it. When the pump is pressed again or manually activated, the saline fluid is moved back into the reservoir, deflating the cuff and allowing urine to pass.

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Artificial Urinary Sphincter (AUS)

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Insertion

  1. 53445: Insertion of Inflatable urethral/ bladder neck sphincter, including placement of pump, reservior and cuff

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Removal

  1. 53446: Removal of Inflatable urethral/ bladder neck sphincter, including placement of pump, reservior and cuff

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Removal and Replacement

  1. 53447: Removal and replacement of Inflatable urethral/ bladder neck sphincter, including placement of pump, reservior and cuff

  2. 53448: Removal and replacement of Inflatable urethral/ bladder neck sphincter, including placement of pump, reservior and cuff through an infected field at the same operative session including irrigation and debridment of infected tissue.

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Repair

  1. 53449: Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir and cuff.

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HIFU stands for High-Intensity Focused Ultrasound, which is a medical treatment that uses high-frequency sound waves to treat various medical conditions, including certain types of cancer and benign tumors.

Main Mechanism:

  1. Focusing Ultrasound Waves: A probe (usually placed on the skin or inserted into the body) directs ultrasound waves towards the target tissue, focusing them in a way that concentrates the energy at a specific point.

  2. Heating the Tissue: The focused energy raises the temperature of the target tissue to 50–100°C, which causes cell death or coagulation.

  3. Precision and Safety: The high-frequency sound waves can penetrate the skin and other tissues without causing harm to surrounding healthy areas. This is achieved through precise targeting of the ultrasound waves.

 

55899 : Unlisted procedure, Male genital System

Overactive Bladder (OAB), also called hypertonic bladder, is a condition characterized by a strong, sudden urge to urinate frequently, even when the bladder isn't full, potentially leading to unintentional urine leakage.

Here are the most common surgical treatments for overactive bladder (OAB):

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1. Sacral Neuromodulation (InterStim Therapy)

  • What It Is: Sacral neuromodulation (SNM) is a minimally invasive procedure that involves implanting a small device (similar to a pacemaker) near the sacral nerves, which control bladder function.

  • How It Works: The device sends mild electrical pulses to the nerves that control the bladder and pelvic floor muscles. These pulses help to regulate bladder activity, reducing the symptoms of urgency, frequency, and incontinence.

  • Indications: SNM is typically recommended for patients who have not responded to medications or behavioral therapy.

  • Procedure: A small electrode is implanted near the sacral nerves, and the device is usually placed under the skin in the upper buttock. The system is adjustable by the patient or healthcare provider.

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 2. Botulinum Toxin (Botox) Injection into the Bladder

  • What It Is: Botox injections into the bladder wall are used to treat OAB symptoms by temporarily paralyzing the overactive bladder muscle (detrusor muscle), preventing it from contracting uncontrollably.
     

  • How It Works: Botox blocks the release of acetylcholine, a neurotransmitter responsible for muscle contraction. This reduces the frequency and urgency of urination.
     

  • Procedure: Botox is injected directly into the bladder muscle using a cystoscope (a thin tube with a camera) inserted through the urethra.
     

  • Indications: Botox is typically used for patients with neurogenic bladder (e.g., due to multiple sclerosis, spinal cord injury) or those who don't respond to other treatments.

Sacral nerve neurostimulator for Bladder Dysfunction

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Implantation or Replacement

  1. 64581 Electrode array Incisional, 64561 Electrode array percutaneous​

  2. 64590 Pulse Generator

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Removal

  1. 64585 Revision or removal of peripheral neurostimulator electrode array

  2. 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver.

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Botox Injection Bladder

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52287 Cystourethroscopy, with injection(s) for chemodenervation of the bladder.

The physician injects a neurolytic drug into the bladder muscle to treat an overactive bladder.

 

​Chemodenervation: A technique in which a provider uses a pharmacologic compound, e.g., botulinum toxin or atropine, to interrupt the neurological signals and paralyzes a muscle or a group of muscles.

ECOIN System

​The eCoin® system is a leadless tibial neurostimulator for the treatment of urgency urinary incontinence (UUI).

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64566 Neurostimulation of posterior tibial nerve with needle/surface electrode (programming)

0587T Neurostimulation of posterior tibial nerve with percutaneous implantaion of neurostimulator (include electrode array, receiver or pulse generator, analysis/ programming and image guidance)

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​55110 Scrotal exploration

In this procedure, the provider inspects the scrotum, the pouch that contains the testes, or testicles, and its contents for any defect or abnormality, such as twisting and or entrapment of the vascular supply to a testicle.

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Calculus Removal from Bladder

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52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

52315 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated

52317 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm)

52318 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)

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CMS Article: CPT codes 52317 and 52318 describe litholapaxy (crushing/fragmentation and removal) of calculus in the urinary bladder. These codes may be reported for crushing/fragmentation with removal of calculi originating from the beginning in the urinary bladder. These codes shall not be reported for crushing/fragmentation and removal of calculi in the urinary bladder that result from a procedure to remove, manipulate, and/or fragment calculi higher up in the urinary tract.

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CMS Article : The code descriptors for CPT codes 52310 and 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure)…) include the “separate procedure” designation. Per CMS payment policy for procedures with the “separate procedure” designation, these codes shall not be reported with other cystourethroscopy CPT codes for the same patient encounter.

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Calculus Removal from Kidney/Renal

52353  Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)

52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

50080 Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (eg, stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)

50081 Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy

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Notes: Coding guidelines indicate 50080 and 50081 do not include creation of percutaneous access or dilation of the tract, so you may report those separately. 

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Calculus removal from renal pelvis

52352: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

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Calculus removal from Ureter

52320: Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus

52325: Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique) 

52330: Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus

52352: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
Note: Insertion of stent will be coded separately.

Stress incontinence is a type of urinary incontinence characterized by the involuntary leakage of urine during physical activities that increase abdominal pressure

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57288 Sling operation for stress incontinence (eg, fascia or synthetic)- Suprapubic/ Pubovaginal/ Pubococcygeal/ Levator muscle

The procedure can be performed abdominally or vaginally depending on whether the provider uses a pubocervical or transvaginal sling.

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57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic)- Suprapubic/ Pubovaginal/ Pubococcygeal/ Levator muscle

The provider removes the sling  because it is eroding, has become infected, is causing urinary retention, or is protruding from the site. This surgery includes a vaginal or combination vaginal and abdominal approach.

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51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic)- Suprapubic/ Pubovaginal/ Pubococcygeal/ Levator muscle

In this procedure, the provider surgically suspends the urethra by placing a sling graft at the junction of the bladder and the urethra. He performs this procedure with a laparoscope

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Pelvic organ prolapse (POP) is a condition in which one or more of the pelvic organs—such as the bladder, uterus, rectum, or vagina—slips down from its normal position and bulges into or out of the vaginal canal.

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Types of Pelvic Organ Prolapse

The specific type of prolapse depends on which organ(s) have fallen or descended into the vaginal canal. The most common types include:

  1. Cystocele (Bladder Prolapse):

    • The bladder drops into the front wall of the vagina. This can lead to urinary incontinence, frequent urination, or the feeling that the bladder is not fully emptied.

  2. Rectocele (Rectal Prolapse):

    • The rectum bulges into the back wall of the vagina. This can cause difficulty with bowel movements, a feeling of incomplete evacuation, or the sensation of a bulge in the vagina.

  3. Uterine Prolapse:

    • The uterus descends into the vaginal canal. In severe cases, it may even protrude outside the vagina. This is most common after childbirth, particularly after vaginal delivery.

  4. Enterocele (Small Bowel Prolapse):

    • The small bowel (part of the intestines) protrudes into the vaginal canal. This is less common but can occur, often after a hysterectomy.

  5. Vaginal Vault Prolapse:

    • This occurs when the top of the vagina (the vaginal vault) drops or sags after a hysterectomy (removal of the uterus). It’s a concern particularly for women who have had a hysterectomy and are experiencing weakened pelvic floor muscles.

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57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed

57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy

57260 Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed

57265 Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair

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. Urinary System

1. Insertion of a urinary bladder catheter is a component of the global surgical package. Urinary bladder catheterization (CPT codes 51701, 51702, and 51703) is not separately reportable with a surgical procedure when performed at the time of or just before the procedure. Revision Date (Medicare): 1/1/2025 VII-5 Additionally, many procedures involving the urinary tract include the placement of a urethral/bladder catheter for postoperative drainage. Because this is integral to the procedure, placement of a urinary catheter is not separately reportable.

 

2. Cystourethroscopy, with biopsy(s) (CPT code 52204) includes all biopsies during the procedure and shall be reported with one unit of service.

 

3. Some lesions of the genitourinary tract occur at mucocutaneous borders. The CPT Professional codebook contains integumentary system (CPT codes 10000-19999 and genitourinary system (CPT codes 50000-59899) codes to describe various procedures such as biopsy, excision, or destruction. A single code from 1 of these 2 sections of the CPT Professional codebook that best describes the biopsy, excision, destruction, or other procedure performed on 1 or multiple similar lesions at a mucocutaneous border shall be reported. Separate codes from the integumentary system and genitourinary system sections of the CPT Professional codebook may only be reported if separate procedures are performed on completely separate lesions on the skin and genitourinary tract. Modifier 59 or XS should be used to indicate that the procedures are on separate lesions. The medical record must accurately describe the precise locations of the lesions.

 

4. If an irrigation or drainage procedure is necessary and integral to complete a genitourinary or other procedure, only the more extensive procedure shall be reported. The irrigation or drainage procedure is not separately reportable.

 

5. The CPT code descriptor for some genitourinary procedures includes a hernia repair. A HCPCS/CPT code for a hernia repair is not separately reportable unless the hernia repair is performed at a different site through a separate incision. In the latter case, the hernia repair may be reported with modifier 59 or XS.

 

6. In general, multiple methods of performing a procedure (e.g., prostatectomy) cannot be performed at the same patient encounter. (See general policy on mutually exclusive services, Chapter I, Section P.) Therefore, only one method of accomplishing a given procedure may be reported. If an initial approach fails and is followed by an alternative approach, only the completed or last uncompleted approach may be reported.

 

7. If a diagnostic endoscopy leads to the performance of a laparoscopic or open procedure, the diagnostic endoscopy may be separately reportable. Modifier 58 may be reported to indicate that the diagnostic endoscopy and non-endoscopic therapeutic procedures were staged or planned procedures. The medical record must indicate the medical necessity for the diagnostic endoscopy. However, if an endoscopic procedure is performed as an integral part of an open procedure, only the open procedure is reportable. If the endoscopy is confirmatory or is performed to assess the surgical field, the endoscopy does not represent a separate diagnostic or surgical endoscopy. The endoscopy represents exploration of the surgical field and shall not be reported separately with a diagnostic or surgical endoscopy code.​

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8. If an endoscopic procedure is performed at the same patient encounter as a nonendoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure.

 

9. If an endoscopic procedure is converted to an open procedure, only the open procedure may be reported. Neither a surgical endoscopy nor a diagnostic endoscopy code shall be reported with the open procedure code when an endoscopic procedure is converted to an open procedure.

 

10. Surgical endoscopy includes diagnostic endoscopy, which is not separately reportable. If a diagnostic endoscopy leads to a surgical endoscopy at the same patient encounter, only the surgical endoscopy may be reported.

 

11. When multiple endoscopic procedures are performed at the same patient encounter, the most comprehensive code accurately describing the service(s) performed shall be reported. If several procedures not included in a more comprehensive code are performed at the same endoscopic session, multiple HCPCS/CPT codes may be reported with modifier 51. (For example, if renal endoscopy is performed through an established nephrostomy with biopsy, fulguration of a lesion, and foreign body (calculus) removal, the appropriate CPT coding would be CPT codes 50557 and 50561-51, not CPT codes 50551, 50555, 50557, and 50561.) This policy applies to all endoscopic procedures, not only those of the genitourinary system.

 

12. CPT code 51700 (Bladder irrigation, simple, lavage and/or instillation) is used to report irrigation with therapeutic agents or as an independent therapeutic procedure. It is not separately reportable if bladder irrigation is part of a more comprehensive service, such as to gain access to or visualize the urinary system. Irrigation of a urinary catheter is included in the global surgical package. CPT code 51700 shall not be misused to report irrigation of a urinary catheter.

 

13. CPT codes 51784 and 51785 describe diagnostic electromyography (EMG). When EMG is performed as part of a biofeedback session, neither CPT code 51784 nor 51785 shall be reported unless a significant, separately identifiable diagnostic EMG service is provided. If either CPT code 51784 or CPT code 51785 is reported for a diagnostic electromyogram, a separate report must be available in the medical record to indicate this service was performed for diagnostic purposes.

 

14. When endoscopic visualization of the urinary system involves several regions (e.g., kidney, renal pelvis, calyx, and ureter), the appropriate CPT code is defined by the approach (e.g., nephrostomy, pyelostomy, ureterostomy, etc.) as indicated in the CPT descriptor. When multiple endoscopic approaches at the same patient encounter are medically reasonable and necessary (e.g., renal endoscopy through a nephrostomy and cystourethroscopy) to perform different procedures, they may be separately reported appending modifier 51 to the less extensive procedure codes. However, when multipleendoscopic approaches are used to attempt the same procedure, only the completed approach shall be reported.

 

15. Endoscopic procedures include all minor related functions performed at the same encounter. Although CPT codes may exist to describe these functions, they shall not be reported separately. For example, transurethral resection of the prostate includes meatotomy, urethral calibration and/or dilation, urethroscopy, and cystoscopy. Codes for the included procedures shall not be reported separately.

 

16. A provider/supplier shall not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. When urethral catheterization or urethral dilation (e.g., CPT codes 51701-51703) is necessary to complete a more extensive procedure, the urethral catheterization/dilation is not separately reportable.

 

17. Ureteral anastomosis procedures are described by CPT codes 50740-50825, and 50860. In general, they represent mutually exclusive procedures that are not reported together. If one type of anastomosis is performed on one ureter, and a different type of anastomosis is performed on the contralateral ureter, the appropriate modifier (e.g., LT, RT) should be reported with the CPT code to describe the service performed on each ureter. For example, the procedure described by CPT code 50860 (Ureterostomy, transplantation of ureter to skin) is mutually exclusive with the procedures described by CPT codes 50800- 50830 (e.g., Ureteroenterostomy, Ureterocolon conduit, Urinary undiversion) unless performed on contralateral ureters, in which case anatomic modifiers should be reported.

 

18. CPT codes 53502-53515 describe urethral repair codes for urethral wounds or injuries (urethrorrhaphy). When an urethroplasty is performed, codes for urethrorrhaphy shall not be reported in addition since “suture to repair wound or injury” is included in the urethroplasty service.

 

19. CPT code 78730 (Urinary bladder residual study) is a nuclear medicine procedure requiring use of a radiopharmaceutical. This CPT code shall not be used to report measurement of residual urine in the urinary bladder determined by other methods.

 

20. CPT code 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)) describes insertion of a self-retaining indwelling stent during cystourethroscopy with ureteroscopy and/or pyeloscopy and shall not be reported to describe insertion and removal of a temporary ureteral stent during diagnostic or therapeutic cystourethroscopy with ureteroscopy and/or pyeloscopy (e.g., CPT codes 52320-52330, 52334-52355).

 

The insertion and removal of a temporary ureteral catheter (stent) during these procedures is not separately reportable and shall not be reported with CPT codes 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;) or 52007 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis)

CPT codes 52332 and 52005 are not separately reportable for the same ureter for the same patient encounter.

 

21. Prostatectomy procedures (CPT codes 55801-55845) include cystoplasty or cystourethroplasty as a standard of surgical practice. CPT code 51800 (Cystoplasty or cystourethroplasty...) shall not be reported separately with prostatectomy procedures.

 

22. CPT code 50650 (Ureterectomy, with bladder cuff (separate procedure)) shall not be reported with other procedures on the ipsilateral ureter. Since CPT code 50650 includes the “separate procedure” designation, CMS does not allow additional payment for the procedure when it is performed with other procedures in an anatomically related area.

 

23. The code descriptors for CPT codes 52310 and 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure)…) include the “separate procedure” designation. Per CMS payment policy for procedures with the “separate procedure” designation, these codes shall not be reported with other cystourethroscopy CPT codes for the same patient encounter.

 

24. Fluoroscopy (CPT code 76000) is an integral component of all endoscopic procedures when performed. CPT code 76000 shall not be reported separately with an endoscopic procedure.

 

25. Cystourethroscopy and transurethral procedures include fluoroscopy when performed. CPT codes describing fluoroscopy or fluoroscopic guidance (e.g., 76000, 77002) shall not be reported separately with a cystourethroscopy or transurethral procedure CPT code.

 

26. A ureteral stent is commonly inserted at the site of an anastomosis of a ureter and another structure to maintain patency of the ureter. A ureteral stent is also often inserted into a ureter if the ureter is incised during a procedure (e.g., nephrectomy, cystectomy, ureteral anastomosis). With these procedures, insertion of the ureteral stent is integral to the procedure and is not separately reportable. For example, CPT code 50605 (Ureterotomy for insertion of indwelling stent, all types) shall not be reported with CPT codes describing cystectomy, urinary diversion, or ureteral anastomosis for insertion of a ureteral stent to maintain patency at the site of a ureteral anastomosis.

 

27. Pelvic exenteration procedures (CPT codes 45126, 51597, 58240) include extensive removal of structures from the pelvis. Providers/suppliers shall not separately report codes for the removal of pelvic structures (e.g., colon, rectum, urinary bladder, uterine body and/or cervix, fallopian tubes, ovaries, lymph nodes, prostate gland).

45126 :Pelvic exenteration for colorectal malignancy, .......

51597 :Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy,........

58240 :Pelvic exenteration for gynecologic malignancy,.......

 

28. CPT code 50435 (Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy)) and all associated radiological supervision and interpretation) describes exchange of a percutaneous nephrostomy catheter, including diagnostic nephrostogram. CPT codes 50430 and 50431 should not be reported separately with 50435.

 

29. CPT codes 52317 and 52318 describe litholapaxy (crushing/fragmentation and removal) of calculus in the urinary bladder. These codes may be reported for crushing/fragmentation with removal of calculi originating from the beginning in the urinary bladder. These codes shall not be reported for crushing/fragmentation and removal of calculi in the urinary bladder that result from a procedure to remove, manipulate, and/or fragment calculi higher up in the urinary tract

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