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Urinary and Male Genital Systems List

STUDY
PLAY
Urinary and Male Genital Systems
Chapter Topics
Urinary System
Male Genital System


Learning Objectives
After completing this chapter you should be able to
1
Understand the format and codes of the Urinary System subsection
2
Review the subheadings and categories of the Urinary System subsection
3
Report services with Urinary System codes
4
Understand the format and codes of the Male Genital System subsection
5
Review the subheadings and categories of the Male Genital System subsection
6
Report services with Male Genital System codes
URINARY SYSTEM

The Urinary System subsection (50010-53899) of the CPT manual is arranged anatomically by the subheadings of kidney, ureter, bladder, and urethra (Fig
...
24-1), with category codes arranged by procedure (i
...
e
...
, incision, excision, introduction, repair)
...
A wide range of terminology is used in the subsection
...
The Glossary at the back of this book includes many of the terms that you will encounter in the CPT manual
...
Always be certain you know the meaning of all the words in the code description before you assign a code
...
Kidney
The first subheading in the Urinary subsection is Kidney (50010-50593)
...
Incision
...
...
The Incision codes (50010-50135) are assigned to report exploration, nephrostomy, drainage, nephrolithotomy, and pyelotomy services
Renal exploration is a procedure performed if the cause of a patient's condition is unknown
...
For example, surgical exploration of an injured kidney when the patient is clinically unstable and appears to be having renal blood loss
...
Access for the exploration procedure is from the side (flank)
...
Note that a parenthetical statement preceding 50010 indicates "For retroperitoneal exploration, abscess, tumor, or cyst, see 49010, 49060, 49203-49205," which are Digestive System codes
...
Code 49010 reports an exploration of the retroperitoneum
...
The term retroperitoneal refers to that area located behind (retro to) the peritoneum (lines the abdominal walls and covers most of the organs) that is located in the abdominal cavity
...
The retroperitoneal space may be accessed by means of an abdominal incision
...
When coding an exploration of the retroperitoneal space, be careful to determine the exact anatomical location(s) explored to report the correct services because there are many organ systems located in the abdominal cavity
...
For example, the kidney is located in the retroperitoneal space
...
If only the kidney was explored, report the service with the Urinary System code 50010
...
if the retroperitoneal area was explored, report the service with the Digestive System code 49010, exploration of retroperitoneal area
...
FIGURE
24-1 The four subheadings of the Urinary System subsection in the CPT manual are: Kidney, Ureter, Bladder, and Urethra
Renal pelvis
Kidney
Ureters
Bladder
Urethra
Meatus


CODING SHOT
Code 50021 has the symbol next to it to indicate that conscious (moderate) sedation is included with the procedure and not reported separately
...
If a procedure begins as an exploratory procedure but becomes a definitive or corrective procedure, such as repair of a lacerated kidney, only the definitive procedure is reported
...
The exploration is considered a diagnostic procedure that is bundled into the definitive procedure when both are performed during the same operative session
...
Open drainage of a perirenal or renal abscess (50020) reports the drainage of a kidney abscess or the surrounding kidney tissue
...
If the drainage was of a retroperitoneal abscess, the service would be reported with the Digestive System code 49060 that reports an open drainage of a retroperitoneal abscess
...
Again, the exact location of the abscess is the critical factor when assigning the abscess drainage code
...
The renal abscess can also be accessed percutaneously, in which case the service would be reported with 50021
...
When performing a percutaneous access to the kidney, fluoroscopy, ultrasound, or computer tomography may be used for guidance of the needle placement and is reported separately with 75989
...
A nephrostomy is a procedure used to decompress the renal system by means of the insertion of a catheter into the kidney while leaving the other end of the catheter outside the body to temporarily drain the kidney
...
The renal collecting system may be obstructed by a calculus or a defect of the renal pelvis or ureter
...
Code 50040 reports incisional placement of a drainage tube that involves incision into the renal pelvis (pyelotomy)
...
The physician then inserts a catheter into the kidney with the other end carried to the skin surface and sutured in place on the flank
...
A nephrotomy is exploration of the inside of the kidney
...
During this exploration (50045), no definitive procedure is performed
...
If a definitive procedure is performed the exploration is bundled into the definitive procedure
...
For example, if the surgeon began a procedure as an exploration to determine the cause of urinary obstruction and identified a renal calculus (kidney stone) and removed the calculus, the procedure no longer would
be an exploration
...
The procedure would be reported with 50060, kidney stone removal (nephrolithotomy)
...
The surgeon may also perform a renal endoscopy at the same time as the nephrotomy (such as, to place stents or perform some other type of repair procedure), and the endoscopy is reported separately with a code from range 50570-50580 (Endoscopy, kidney)
...
Nephrolithotomy procedures include removal of calculus (50060), secondary surgical operation for calculus (50065), procedures complicated by congenital kidney abnormality (50070), and removal of a staghorn calculus (50075)
...
The staghorn calculus (Fig
...
24-2) is shaped like a deer antler and can become large and create extensive obstruction
...
If the calculus involves the renal pelvis and at least two calyces, it is classified as a staghorn calculus
...
These types of stones account for about 30% of stones reported and are usually associated with urinary infections
...
With a staghorn, a nephrolithotomy may be performed after extracorporeal shock wave lithotripsy (ESWL), which fragments the stones (50590)
...
ESWL used to be performed with a machine in which the patient was submersed in a fluid
...
Newer machines do not require submersion, rather the patient is placed on an x-ray table, and a water-filled cushion is placed under the patient's back (Fig
...
24-3)
...
The procedure is performed under general




anesthesia in an operating room with a built-in ESWL machine
...
The shock waves are targeted to the stones by means of x-ray and pulverize the stones with repeated shocks
...
Usually, the particles subsequently pass through the urinary tract
...
Percutaneous nephrolithotomy (nephrolithotripsy) is a more invasive method of treating kidney stones and usually is performed with ultrasound
...
An incision is made over the kidney, a probe is inserted, and shock waves pulverize the stone
...
Electrohydraulic or mechanical lithotripsy may be used instead of shock waves, but the use of shock waves is the most common method
...
A tiny basket may also be attached to a probe that is passed into the kidney and the stones removed
...
Because the stone fragments of a staghorn are so large, they may not pass through the urinary system spontaneously, and an open or percutaneous procedure may need to be performed to remove the fragments
...
The lithotripsy is reported separately (50590 lithotripsy or 52353 cystourethroscope with lithotripsy)
...
F I G U R E
2 4 - 2
Large staghorn calculus inside the kidney filling the pelvis and calyceal system
...
Kidney calculus
Renal cortex
Staghorn calculus
Large staghorn calculus resembles deer antler
X-ray

Percutaneous nephrostolithotomy (PCNL) or a pyelostolithotomy is a procedure to remove kidney stones
...
In this procedure, entry is through the patient's back
...
The procedure is reported based on the size of the stone removed (50080, to 2 cm
...
50081, 2 cm)
...
Internal lithotripsy is included in 50080 and 50081 and is not reported separately
...
External lithotripsy is not included in the codes and can be reported in addition to 50080 and 50081
...
but remember to attach modifier -51 to the lesser procedure
...
The procedure is performed with fluoroscopic guidance that is reported separately with 76000 for the radiologist or 76001 for the radiologist who assists a nonradiological physician
...
Excision
...
...
There are Excision codes in the Kidney subheading for biopsy, nephrectomy (removal of the kidney), and removal of a cyst
The biopsy codes (50200, 50205) are based on the approach, either percutaneous (through the skin) or by surgical exposure of the kidney
...
A nephrectomy is the removal of a kidney, either partial or radical (total)
...
A radical nephrectomy includes removal of the fascia and surrounding fatty tissue, regional lymph nodes, and the adrenal gland
...
The nephrectomy codes (50220-50240) are based on the complexity and extent of the procedure
...
Nephrectomies can also be performed by means of a laparoscope (50543, 50545-50548), based on whether the procedure was partial, radical, or donor, and whether the procedure included a partial or total ureterectomy
...
Ablation is the cutting away or erosion of tissue
...
Code 50250 reports ablation of a kidney lesion by means of cryosurgery (use of subfreezing temperatures) and is usually performed with ultrasonic guidance
...
If used, the ultrasonic guidance is not reported separately because it is included in the code description
...
Monitoring is also included in the code
...
The surgeon accesses the kidney through an incision and inserts a cryosurgical probe into the lesion
...
The cryosurgical machine is turned on, and subfreezing temperature is delivered to the lesion (Fig
...
24-4)
...
The area is brought back to above freezing, and the treatment is applied again
...
At times, more than two cycles are applied to ensure the lesion is ablated
...
This procedure can also be performed percutaneously (50593) or by use of a laparoscope (50542)
...
Renal Transplantation
...
...
Allotransplantation is the transfer of tissue or an organ between two people who are not related (genetically different)
Autotransplantation is transfer of tissue from one part of a person's body to another part of that person's body, also known as autograft or autotransplant
...
A surgeon may perform a renal autotransplant to reposition the kidney, which may be necessary when the kidney has been severely damaged from trauma or disease
...
A renal autotransplantation is reported with 50380
...
Backbench work is the work involved in preparation for the transplant surgery and includes:
n
Open organ retrieval from a deceased (50300) or living (50320) donor
laparoscopic organ retrieval from a living (50547) donor
...
n
Standard preparation based on deceased (50323) or living (50325) donor
As a part of this preparation the surgeon may perform additional surgery on the organ, such as venous, arterial, or ureteral anastomosis (50327-50329)
...
n
Allotransplantation service reported with 50360 (without nephrectomy) or 50365 (with nephrectomy) with modifier -50 added for a bilateral procedure
If backbench procedures were performed, those services would be reported in addition to the transplantation service with modifier -51 added to indicate multiple procedures
...
CODING SHOT
If the recipient requires a nephrectomy, the procedure is reported separately with 50340 and with modifier -50 for a bilateral procedure
...
Introduction
...
...
Introduction category codes in the Kidney subheading are for aspiration, catheters, injections for radiography, guides, and tube changes
There are also extensive notes within the category
...
Codes in the range 50382-50389 are percutaneous, transurethral, or externally accessible procedures that report removal and/or replacement of renal stents and tubes
...
These stents are not renal artery stents but are ureteral stents that are placed through the renal pelvis
...
The codes only report a unilateral procedure, so if a bilateral procedure was performed, add modifier -50
...
Imaging guidance is used for the codes in this range and is included in the code description, so do not report the guidance separately
...
If imaging guidance was not used for removal without replacement of an externally accessible ureteral stent, you would report the removal with an E/M code
...
Approximately half of the population over age 50 has renal cysts that are asymptomatic (no symptoms) and are often only discovered as an incidental finding on ultrasound or computed tomography
...
When these cysts are symptomatic, percutaneous aspiration or injection may be performed
...
The procedure is performed by use of local anesthetic and on an outpatient basis
...
A sclerosing agent (such as alcohol) may be injected into the cyst
...
The code description for 50390 indicates "aspiration and/or injection," which means if both an aspiration and injection are performed during the same operative session, 50390 is reported only one time
...
Image guidance is not included in the code description, so any guidance used is reported separately
...
Repair
...
...
Repair category codes (50400-50540) include plastic surgery (pyeloplasty), suturing (nephrorrhaphy), and closure of fistula
Pyeloplasty is a surgical procedure for an obstruction of the ureteropelvic junction (UPJ), which connects the renal pelvis to the ureter (Fig
...
24-5)
...
Usually, this is a congenital condition, but it may also be an acquired condition
...
If an obstruction occurs the urine will not drain, which results in dilatation of the collecting system and enlargement of the renal pelvis (hydronephrosis)
...
The goal of a pyeloplasty is to remove the obstruction and repair the renal pelvis (Fig
...
24-6)
...
As a part of the repair, a nephropexy (surgical fixation of mobile kidney), nephrostomy (a passageway from the kidney to exterior of the body), pyelostomy (a passageway between the renal pelvis and the exterior of the body), and ureteral splinting are included in the codes for a simple pyeloplasty (50400)
...
A complicated pyeloplasty (50405) includes all of the procedures in the simple pyeloplasty, as indicated by the placement of the semicolon in 50400
...
(Note that the semicolon is after the term "splinting," which means that all the terms that precede the semicolon are included in the code description for the indented code 50405
...
) In addition to all the procedures in the simple pyeloplasty, the complicated pyeloplasty is more difficult, because the procedure may include repair of a congenital kidney abnormality (which can be an extensive procedure), further plastic repair of the pelvis of the kidney, repair of a solitary kidney (patient only has one kidney), or a calycoplasty
...
A calycoplasty is repair of the calyx (the cup-shaped structure) of the kidney
...
FIGURE
24-5
Ureteropelvic junction (UPJ) is the place at which the ureter joins the kidney at the renal pelvis
Cortex
Medulla
Parenchyma
Calyx
Hilum
Renal vessels
Renal pelvis
Ureter
Capsule
Pelvis of kidney
Ureteropelvic junction
Ureter
Perirenal fat


Closures of nephrocutaneous, pyelocutaneous, or nephrovisceral fistulas (abnormal openings) are reported with codes from the 50520-50526 range
...
Code 50520 reports the closure of a fistula between the renal pelvis and the exterior of the body or of the kidney and the exterior
...
Codes 50525 and 50526 report closure of a fistula between the kidney and another organ, such as the kidney and the bladder
...
The approach to close the fistula may be abdominal (50525) or thoracic (50526)
...
Laparoscopy
...
...
The Laparoscopy codes (50541-50549) report ablation of renal cysts (50541) or lesions (50542)
Open cryosurgical ablation of renal tumors is reported with 50250, and percutaneous ablation is reported with 50593
...
Laparoscopic nephrectomies and pyeloplasty are also reported with codes from the Laparoscopy category and are based on the extent of the procedure
...
Endoscopy
...
...
Endoscopy codes (50551-50580) are frequently reported for kidney procedures, because these types of procedures are less invasive than the open procedures and are often performed in an outpatient setting
Renal endoscopies may be performed by means of an established connection between the kidney and the exterior of the body
...
The codes in the Endoscopy category are divided into those procedures performed through an established nephrostomy or pyelostomy and those that are not
...
For example, 50555 reports a renal endoscopy through an established nephrostomy/pyelostomy, and 50574 reports the same endoscopic biopsy but not through a nephrostomy/ pyelostomy
...
The codes are further divided based on the reason for the procedure: ureteral catheterization, biopsy, fulguration, or foreign body/ calculus removal or tumor resection
...
The code descriptions in the Endoscopy category code descriptions state "exclusive of radiologic service," which means that the radiologic services are reported in addition to the endoscopic procedures
...
If, for example, a biopsy (50555) is performed with ultrasound, you would report the biopsy procedure in addition to the ultrasound
...
Kidney Index Locations
...
...
You will locate the kidney codes in the CPT manual index under "Kidney"
they are subtermed primarily by category (e
...
g
...
, insertion, excision, or repair)
...
Another method of locating kidney codes in the CPT manual index is to reference the medical term for the procedure (e
...
g
...
, nephrostomy or nephrotomy)
...
Again, there are other index location methods
...
these are just a couple to help you get started locating the codes
...
The following kidney codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:
50080-50081, 50120-50135 Incision
50200-50230 Excision
50320, 50340, 50360, 50365 Renal Transplantation
50382-50390, 50392-50398 Introduction
50545-50547, 50549 Laparoscopy
50551-50561, 50570-50580 Endoscopy
50590, 50592Other Procedures
The third-party payer may require the use of -RT and -LT rather than modifier -50
...
Ureter
The next subheading (50600-50980) in the Urinary System subsection is Ureter
...
The codes are based on the procedure (i
...
e
...
, incision, excision, introduction, repairs, laparoscopy, or endoscopy)
...
The ureter is the tube that leads from the kidney to the bladder and may be the site of an assortment of conditions, such as obstruction by calculus, cysts, or lesions in addition to reflux, congenital abnormalities, and fistulas
...
Incision
...
...
The Incision codes (50600-50630) report open procedures to explore or drain (50600), insert indwelling stent (50605), and removal of calculus (ureterolithotomy) based on the location of the calculus as upper third, middle third, or lower third of the ureter (50610-50630)
The incisional procedures also have laparoscopic, endoscopic, and/or transvesical counterparts
...
For example, to report a laparoscopic ureterolithotomy of the upper third of the ureter, report 50945, and for an incisional ureterolithotomy, report 50610
...
It is very important to check the documentation for the method utilized for the procedure to ensure selection of the correct code
...
Excision
...
The codes in the Excision category (50650, 50660) report ureterectomy either with bladder cuff or a total excision
...
The bladder cuff is the tissue that connects the ureter to the bladder, and the excision of the bladder cuff is only reported if it is the only procedure performed during the surgical session
...
A total ureterectomy may be performed by means of an abdominal, vaginal, or perineal approach or a combination of the three approaches
...
Code 50660 includes all three approaches or a combination of approaches
...
This means that if two or three approaches were utilized, you still only report 50660 one time
...
Introduction
...
...
The Introduction codes (50684-50690) include injection procedures, manometric studies (see paragraph below), and change of tubes and/or stents
Code 50684 reports an injection procedure performed through an indwelling catheter to determine the status of the renal collecting system
...
The physician injects a contrast agent through the catheter and an x-ray is taken
...
The radiological supervision and interpretation is reported separately with 74425
...
Manometric studies (50686) are tests to measure kidney and ureter flow and pressure
...
The study is conducted by means of a machine (manometer) through an access site, which is connected to an ureterostomy or ureteral catheter filled with fluid
...
A tube carrying sterile fluid is inserted through the access site and into the kidney or bladder and the area is flooded
...
The pressures and flow are then measured and recorded
...
Repair
...
...
Repair procedures (50700-50940) includes ureteroplasty (plastic repair of the ureter), ureterolysis (freeing of fibrous tissue), ureteropyelostomy (connection of upper ureter to renal pelvis), ureterocalicostomy (connection of upper ureter to renal calyx), and ureteroureterostomy (bypass of obstructed ureter), in addition to numerous other procedures to repair the ureter
Laparoscopy
...
...
Laparoscopic ureter codes 50947 and 50948 report the placement of a ureteral stent, which may be performed in conjunction with or without cystoscopy
The stent is placed because of an obstruction of the ureterovesical junction (UVJ)
...
The surgeon laparoscopically repositions the ureter on the bladder and then by means of the cystoscope places the ureteral stent
...
CAUTION
Watch the Repair codes for use of modifier -50! Unless stated, the procedure is unilateral and requires modifier -50 for bilateral procedures
CMS RULES
According to CMS, 50955 and 50684 cannot be reported together as CMS bundles these codes
...
Only if 50684 is a uniquely distinct procedure could you report it with 50955
...
You must add modifier -59 to the 50684 code
...
Refer to Fig
...
24-7 for an example of the codes that are bundled into 50955
...
This figure illustrates that 50684 is bundled into 50955
...
In the far right column, the number 1 indicates that the code can be reported separately with modifier -59 (distinct procedure) added, and the 0 indicates that the code cannot be reported with -59 and is always bundled with the primary code
...
Endoscopy
...
...
The Endoscopy codes (50951-50980) report procedures that are performed through an established stoma (ureterostomy, 50951-50961) or through an incision into the ureter (ureterotomy, 50970-50980)
The procedures conducted through a ureterostomy are similar to the types of procedures conducted through a nephrostomy (e
...
g
...
, 50551-50562, biopsy, catheterization, irrigation, and instillation)
...
Excellent medical terminology skills are essential for working within this subheading, because the words can be intimidating
...
Keep your medical dictionary close by to look up any words you are not absolutely sure about
...
You can also refer to the Glossary at the back of the book
...
The time you spend now increasing the depth and breadth of your medical terminology is an excellent investment and will greatly increase your coding accuracy
...
The endoscopy procedures are for irrigation, instillation, catheterization, biopsy, fulguration, and foreign body or calculus removal
...
The procedures often utilize radiological services, but these services are reported separately
...
Note that the stand-alone code descriptions in the category (50951, 50970) indicate that the service is "exclusive of radiologic service," meaning that you report those services in addition to the procedure
...
This also means that all indented codes that follow 50951 and 50970 do not include radiologic services
...
When a ureterocystography is performed, the physician injects a radioactive contrast material through a catheter inserted into the bladder via the urethra or through a previously established stoma
...
The injection procedure is reported in addition to the primary procedure
...
For example, if the procedure was an endoscopic biopsy of the right ureter through an established stoma, you would report 50955-RT and the injection procedure would be reported with 50684-RT
...
In addition to the primary and injection procedures, you also report the radiological supervision and interpretation with a Radiology code
...
For example, 74425 reports retrograde urography
...
Retrograde urography is performed by injecting contrast directly into the lower end of the system, and the contrast flows backwards through the system allowing for visualization of the tract
...
The following ureter codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:
50601-50630 Incision
50684 Introduction
50715 50780-50800, 50815, 50820 Repair
50840, 50860, 50940 Repair
50945-50980 Repair Laparoscopy/Endoscopy
The third-party payer may require the use of -RT and/or -LT rather than modifier -50
...
FIGURE
24-7 Codes bundled into 50955
Code
50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955 50955
Bundled
J2001 00910 0213T 0216T 36000 36400 36405 36406 36410 36420 36425 36430 36440 36600 36640 37202 43752 50684 50715 50951 51701 51702 51703 76000 76001 93000 93005 93010 93040 93041 93042 93318 94002 94200 94250 94680 94681 94690 94770 95812 95813 95816 95819 95822 95829 95955 96360 96365 96372 96374 96375 96376


Bladder
The Bladder subheading (51020-52700) contains codes not only for the usual services, such as incision and excision, but also for some unique services such as urodynamics and procedures performed on the prostate
Review the anatomy of the bladder in Fig
...
24-8
...
FIGURE
24-8 Bladder anatomy
Urachus
Dome
Posterior wall
Lateral wall
Anterior wall
Ureteral orifice
Trigone
Bladder neck

Incision
...
Cystotomy (51020-51045) is often performed to fulgurate (use of electric current), insert radioactive material, or cryosurgically to destroy a lesion
...
In addition, the procedure is used for drainage, placement of catheter/stent, or a cystolithotomy (removal of calculus)
...
A cystolithotomy reported with 51050 is one in which an incision is made in the skin and into the bladder
...
The physician removes the calculus through the incision but does not excise the bladder neck
...
A transvesical ureterolithotomy described in 51060 is a similar procedure to 51050, but the calculus is removed through an incision in the bladder and the ureter
...
The ureter calculus is removed by basket extract through an incision in 51065, and in some cases the calculus is first fragmented by ultrasound or electrohydraulic means
...
Electrohydraulic fragmentation is the use of a probe containing two electrodes that are applied, one on each side of the calculus
...
Electrical current is then directed through the electrodes, which fragments the calculus
...
Removal
...
...
Aspiration of urine from the bladder may be accomplished by means of needle, trocar (a sharply pointed surgical instrument), or intracatheter (plastic tube with a needle on the end)
A suprapubic (above the pubic bone) catheter may also be inserted during the aspiration service (51102)
...
Aspirations are often performed by means of imaging guidance, which is reported separately
...
If imaging guidance is used, report the guidance separately with 76942, 77002, or 77012
...
Excision
...
...
A urachal cyst is between the umbilicus and bladder dome and is often diagnosed in young children when the cyst becomes infected
Because of the proximity to the abdominal cavity and potential to rupture, a urachal cyst is a condition that warrants prompt medical attention
...
A urachal sinus is a congential abnormality in which prenatal tissue remains, causes drainage to the umbilicus, and results in infection
...
The excision of a urachal cyst or sinus is reported with 51500 and may or may not include umbilical hernia repair
...
Cystotomies and cystectomies (51520-51596) are performed for a variety of reasons, such as excision of a portion of or all of the bladder, repair of a ureterocele, or to replant a ureter into the bladder
...
The codes are divided based on the extent of the procedure
...
If the procedure is performed transurethrally, such as a bladder resection, codes from the Transurethral Surgery category (52204-52318) would be reported
...
Pelvic exenteration (51597) is also known as total pelvic exenteration (TPE) and is the removal of the pelvic organs and adjacent structures due to malignancy
...
If TPE is performed due to gynecologic malignancy, report the service with the Female Genital system code 58240
...
A hysterectomy may be performed with 51597, but the initial and primary reason the procedure is being performed is for other than a gynecological malignancy
...
Introduction
...
...
The injection procedures reported with codes 51600- 51610 are for urethrocystography (x-ray of lower urinary tract, also known as a cystourethroscopy)
The radiological supervision and interpretation are reported in addition to the injection procedure
...
Note that the parenthetical statements after each of the injection codes direct the coder to the correct radiology code(s)
...
Insertion of bladder catheters may be non-indwelling (51701) or temporary indwelling (51702, 51703)
...
The non-indwelling catheter is the type that is inserted into the urethra and manipulated into the bladder to drain residual urine
...
The temporary indwelling procedure can be a simple catheterization (such as with a Foley) or a complicated catheterization due to an anatomical anomaly
...
Catheter fracturing may occur, for example, when a patient pulls the catheter out while the balloon is still inflated
...
This is a rare complication and does not describe the insertion but rather why it was necessary to reinsert another catheter
...
Instillation is a procedure that is performed for bladder cancer
...
An anticarcinogenic agent is introduced into the bladder by means of a catheter
...
For example, immunotherapy is the instillation of a nonactive tuberculosis agent into the bladder
...
The agent is retained in the bladder for a period of time (such as 1 hour) with the patient in a supine position
...
The agent is then drained and the treatment is concluded
...
A series of these instillations is performed in a course of treatment
...
Code 51720 reports the instillation as well as the retention time and drainage
...
Urodynamics
...
...
Urodynamics pertains to the motion and flow of urine
Urinary tract flow can be obstructed by renal calculi, narrowing (stricture) of the ureter, cysts, and so forth
...
The procedures in the Urodynamics subheading (51725-51798) are to be conducted by or under the direct supervision of a physician, and all the instruments, equipment, supplies, and technical assistance necessary to conduct the procedure are bundled into the codes
...
If the physician performs only the professional service (e
...
g
...
, interpretation of the results), modifier -26 (professional component) is reported with the code to indicate that the technical portion of the service (performance of test or tests) was provided elsewhere
...
For example, if a physician provides only the interpretation (-26) of a complex urethral pressure profile (UPP) (51727), report only the professional component of the service as 51727-26
...
Repair and Laparoscopy
...
...
Repair procedures (51800-51980) include procedures such as cystoplasty (bladder repair), cystourethroplasty (bladder and urethra), vesicourethropexy/urethropexy (repair for urinary incontinence), and closure of fistulas
CODING SHOT
For a complete list of the CMS Correct Coding Initiative (CCI) edits, check out www
...
cms
...
gov/NationalCorrectCodInitEd/
...
Stress incontinence may be surgically repaired by a colposuspension procedure in which a urethral sling is placed to support and elevate the urethra
...
There are several types of these sling procedures, such as the Marshall-Marchetti-Krantz (MMK), Burch, paravaginal repair, anterior vesicourethropexy, or urethropexy
...
These procedures are reported with 51840 for a simple procedure and 51841 for a complicated repair, which would include a secondary repair of the bladder
...
The urethral suspension and sling operation are also performed by means of laparoscopy (51990, 51992)
...
A sling operation for stress incontinence is also reported with 57288 when vaginal and abdominal incisions are used
...
A Pereyra procedure (57289) is also known as a needle bladder neck suspension in which sutures are used to support and anchor the bladder
...
The codes (57287-57289) are in the Female Genital System subsection, Vagina subheading, because the procedure includes repair of the vagina
...
There are also codes in the Urethra subsection (53431-53442) that refer to the creation, removal, or revision of a sling operation for male urinary incontinence and plastic repair of the bladder for incontinence
...
Endoscopy
...
...
There are codes (52000-52010) for bundled endoscopy procedures (i
e
...
, cystoscopy, urethroscopy, and cystourethroscopy)
...
The codes contain the primary procedure of a cystourethroscopy (endoscopic procedure to view the bladder and urethra) and minor related procedures performed at the same time
...
For example, if a cystourethroscopy is performed for the biopsy of the ureter with radiography, bundled into the code for the procedure (52007) are the catheterization, endoscopic procedure, and biopsy(ies)
...
To unbundle the code and report the individual components of the procedure separately would not be correct
...
If the secondary procedure(s) required significant additional time or effort that is documented in the medical record, the procedure can be identified using modifier -22 (increased procedure)
...
There are combination codes that include many components of a procedure bundled into one code
...
For example, 52005 reports a cystourethroscopy with ureteral catheterization, with/without irrigation, instillation, or ureteropyelography with the one code
...
Be careful to read each description in this category before assigning a code to be certain you have identified each component included in the code before you assign additional codes
...
For example, you cannot report a cystourethroscopy (52005) with a catheterization (51701) because a catheterization is included in the code description for 52005
...
Many third-party payers, such as CMS, have lists of codes (edits) that cannot be reported with other codes
...
For example, 52000 (cystourethroscopy) cannot be reported with 51701 (catheterization), even though catheterization is not stated in the code description
...
You need to know not only the limitations set by the notes and codes in the CPT manual but also the limitations set by the third-party payer
...
A cystourethroscopy is a diagnostic procedure to assess lower urinary tract symptoms (LUTS), such as incontinence or benign prostate hypertrophy (BPH)
...
The procedure is reported only if it is performed as the only procedure during the operative session, because it is designated a separate procedure
...
CODING SHOT
Usually, third-party payers will not reimburse for more than two cystourethroscopic procedures per episode of illness unless bladder or urethral malignancies are being treated
...
Transurethral Surgery
...
...
Transurethral Surgery codes (52204-52355) are for the urethra/bladder (52204-52318) and ureter/pelvis (52320-52355)
Code 52204 reports a cystourethroscopy with biopsy and 52000 is also a cystourethroscopy
...
The difference is that 52000 is a diagnostic procedure only
...
No additional procedure was performed when reporting 52000
...
When reporting 52204, a biopsy was performed, so the procedure was not only diagnostic but also a surgical procedure
...
The procedure may have begun as a diagnostic procedure, but it progressed to a biopsy on identification of a lesion
...
The diagnostic procedure is then bundled into the surgical procedure and not reported separately
...
CODING SHOT
Many third-party payers will bundle 52204 (cystourethroscopy) into many major procedures
...
For example, Medicare bundles the cystourethroscopy into the transurethral resection of a bladder tumor (52234-52240)
...
A transurethral resection of a bladder tumor (TURBT) is a procedure in which a bladder tumor is removed by fulguration (electric current) or excision
...
Note that the code descriptions 52234-52240 contain multiple methods of removal of the bladder tumor, that is, "with fulguration (including cryosurgery or laser surgery) and/or resection
...
" If any, or a combination of, these methods has been used to eradicate the tumor, you can assign a code based on the size of the bladder tumor
...
The code description indicates the size as small (0
...
5-2
...
0 cm), medium (2
...
0-5
...
0 cm), and large (5 cm)
...
Code 52224 is a cystourethroscopy with fulguration or treatment of a minor (0
...
5 cm) lesion(s)
...
The lesion(s) are treated with fulguration (electrocautery), cryosurgery or a laser
...
This procedure may or may not include a biopsy prior to eradication
...
Many of the code descriptions require the coder to be familiar with the anatomy of the bladder and surrounding structures, for example, 52214 (cystourethroscopy) with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
...
Refer to Fig
...
24-8 for bladder anatomy and location of the trigone and bladder neck
...
To code correctly the coder also needs to know the anatomy surrounding the bladder, such as the prostatic fossa, which is the depression or cavity (prostatic bed) in which the prostate is located
...
The codes in the Ureter and Pelvis subsection (52320-52355) all include insertion and removal of temporary stents during the procedure, even though the code descriptions may not all state that fact
...
You know this only when you read the notes preceding code 52320
...
That does not mean that insertion and/or removal of temporary stents cannot be reported with other procedures, such as ESWL (50590), only that temporary stents are not reported separately with the codes in the 52320-52355 range
...
Make a note in your CPT manual next to this range of codes stating "includes insertion/removal of temporary stents" as a reminder of this important point or highlight the paragraph in the notes preceding code 52320 ("The insertion and removal of a temporary ureteral catheter
...
")
...
Insertion of indwelling stents is reported separately with 52332-51
in addition to the primary procedure
...
Code 52332 reports insertion of unilateral stents, so modifiers to indicate bilateral procedures were performed would also be needed
...
for example, 52332-51-50
...
To report removal of indwelling stents, use 52310 (simple removal) or 52315 (complicated removal) with modifier -58 (staged or related procedure or service by same individual during the postoperative period)
...
It is a good idea to place a bracket next to codes 52310 and 52315 and write "-58" as a reminder of how to report these codes, because the direction for the use of this modifier is located in notes before code 52320
...
Vesical Neck and Prostate
...
...
The Vesical Neck and Prostate codes 52400-52700 contain codes to report cystourethroscopy and transurethral procedures
Many of these codes are reviewed in the Male Genital System information because many of these procedures are of the prostate with access through the urethra, such as 52450, transurethral incision of the prostate
...
When the procedure is a transurethral resection of the bladder neck, report 52500
...
If a transurethral incision of the bladder neck is performed, report 52276 (Bladder, Urethrotomy)
...
The following bladder codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:
52007
Endoscopy/Cystoscopy, Urethroscopy and Cystourethroscopy
52320-52344, 52352-52355 Ureter and Pelvis
The third-party payer may require the use of -RT and/or -LT rather than modifier -50
Urethra
The subheading Urethra contains codes (53000-53899) for the usual procedures of incision, excision, and repair
...
For endoscopic procedures of the urethra, refer to codes 52000-52700, which contain cystoscopy, urethroscopy, and cystourethroscopy procedures
...
If the physician performs the injection procedure for radiology studies for examination of the urethra, report 51600-51610 based on the type of study being performed
...
The radiological supervision and interpretation is reported separately with 74430 (cystography), 74450 (retrograde urethrocystography), or 74455 (voiding urethrocystography)
...
Incision
...
...
A meatotomy is surgical incision of the meatus, which is the opening of the urethra to the outside of the body (urethral meatus)
This procedure is often bundled into other more major procedures
...
Codes 53020 (except infant) and 53025 (infant) report a meatotomy if it is performed as a separate procedure
...
Because 53025 is specifically for infants, do not append modifier -63 (Procedure performed on infants less than 4 kg)
...
The Skene's glands are also known as the paraurethral or the lesser vestibular glands and are located on either side of the urethra
...
These glands drain into the urethra near the meatus (urethral opening)
...
When infected, the gland will become enlarged and tender and may require drainage or excision
...
Drainage of an abscess or cyst of the Skene's glands is reported with 53060
...
Excision of the Skene's glands is reported with code 53270
...
Excision
...
...
The Excision category of codes (53200-53275) includes services such as biopsy, urethrectomy, lesion excision, fulguration, and marsupialization (creating a pouch)
When the urethra is totally surgically removed (urethrectomy), the service is reported with 53210 for a female and 53215 for a male
...
A urethrectomy involves removal of the urethra and creation of an opening from the bladder to the skin that is then used to drain urine
...
The procedure would include removal of any tumors of the urethra
...
If the urethra was not removed and only the tumor was removed, report with 53220
...
The bulbourethral gland is also known as the Cowper's gland and is a pair of glands about the size of a pea located beneath the prostate
...
These glands secrete a fluid that forms part of the semen and drains directly into the urethra
...
Excision of the bulbourethral gland is reported with 53250
...
Repair
...
...
A urethroplasty may be completed in one stage or two stages (53400-53431)
The choice of codes to report a urethroplasty is based on the number of stages and type of repair
...
Codes 53420 (first stage) and 53425 (second stage) report the two stages of an urethroplasty, and 53415 reports a one-stage urethroplasty
...
A tandem cuff or dual cuff is an artificial urinary sphincter (AUS) that is placed due to atrophy, disease, or defect of the urinary sphincter and reported with 53444
...
An artificial sphincter is inflatable and includes a pump, reservoir, and cuff, is inserted through a subpubic incision, and is illustrated in Fig
...
24-9
...
The small switch in the scrotum can be manipulated to activate the pump and control urinary continence
...
Codes 53446-53448 report the removal and/or replacement of an AUS system, and 53449 reports repair of a previously placed system
...
Urethromeatoplasty is repair of the meatus and the urethra (53450, 53460) and is performed to open and/or reconstruct the urethra
...
Manipulation
...
...
The Manipulation category codes (53600-53665) are a bit different from those you have encountered previously
Manipulation is performed on the urethra (e
...
g
...
, dilation or catheterization)
...
Dilation stretches or dilates a passage that has narrowed
...
The Dilation codes are based on initial or subsequent dilation of a male or female patient
...
MALE GENITAL SYSTEM
Format
The Male Genital System subsection (54000-55899) of the CPT manual is divided into anatomic subheadings (penis, testis, epididymis, tunica vaginalis, scrotum, vas deferens, spermatic cord, seminal vesicles, and prostate) (Fig
...
24-10)
...
The category codes are divided according to procedure
...
The greatest number of category codes are under the subheading Penis because there are many repair codes in this subheading
...
The other subheadings are primarily for incision and excision, with only a few repair codes for the remaining subheadings
...
FIGURE 24-10 Male genital system
...
Symphysis pubis
Vas deferens
Penis
Urethra
Testis
Scrotum
Urinary bladder
Seminal vesicle
Prostate
Bulbourethral gland
Epididymis



FIGURE 24-10 Male genital system, Testis
Spermatic cord
Tunica vaginalis
Epididymis Testis

Penis

Incisions
...
...
Under the Incision category (54000-54015) of the subheading Penis, there is an incision and drainage code (54015)
Recall that under the Integumentary System section there are incision and drainage codes
...
The code from the Penis subheading is for a deep incision, not just an abscess of the skin
...
For the deep abscess described in 54015, the area is anesthetized, the abscess is opened and cleaned, and often a drain is placed to maintain adequate drainage
...
Destruction
...
...
Under the Destruction category (54050-54065) of the subheading Penis there are also destruction codes for lesions of the penis
These lesion destruction codes are divided on the basis of whether the destruction is simple or extensive
...
Simple destruction is further divided according to the method of destruction (e
...
g
...
, chemical, cryosurgery, laser)
...
The code for extensive lesion destruction can be reported no matter which method was employed to accomplish the extensive destruction
...
Excision
...
...
Excision codes (54100-54164) include codes to report biopsy of the penis (54100, 54105)
Note that 54100 has a designation of "separate procedure," which means that the code is reported when the biopsy was the only procedure performed during the operative session
...
To accomplish the biopsy, the physician removes a portion of a lesion by excision of a small section of the lesion (scalpel or scissors) or by a punch biopsy
...
A punch biopsy is commonly used with skin lesions and is performed with an instrument that is pencil-shaped (Fig
...
24-11) that removes a round disk of tissue
...
The opening left by the punch may require simple closure (suture) depending on the size of the skin defect created by the biopsy
...
A more complex biopsy (54105) of the penis involves the deeper layers of the penis and may require layered closure, which is reported separately
...
Peyronie disease is a curvature of the penis that results from plaque formation on the cavernous sheaths of the penis as illustrated in Fig
...
24-12
...
The plaque develops on the lower and upper side of the penis where the erectile tissue is located
...
Inflammation results and leads to the formation of scar tissue
...
Over time, this fibrous plaque bends the penis
...
In severe cases, the penis arches during erection, causing pain
...
Surgical correction of the curvature involves removal of the penile plaque (54110-54112)
...
Grafting of the defect may be necessary, depending on the extent of the removal
...
Code 54110 reports the excision of penile plaque when no grafting is required and 54111/54112 report excision when grafting is required
...
Penile amputation can occur as a result of trauma or as a surgical procedure for penile cancer
...
If the procedure is the removal of only the penis (partial or complete), report the service with 54120 or 54125
...
If the procedure includes removal of the inguinofemoral lymph nodes, report the service based on the extent of the removal (54130, 54135)
...
Circumcision codes 54150-54161 are divided based on whether the circumcision was accomplished by means of a clamp/other device or surgical excision and whether the procedure was performed on a neonate or non-neonate
...
A clamp is a device that is used to restrain the foreskin of the penis while the skin is trimmed
...
Report newborn circumcisions that utilize a clamp or other device with 54150
...
Surgical excision of the foreskin is a procedure in which a clamp or other device is not used, and the surgeon directly excises the skin from the penis
...
Once the skin has been removed, the incision is closed with sutures
...
Report the surgical excision without the use of a clamp or other device with 54160 (neonate) or 54161 (except neonate)
...
FIGURE 24-11 Curvature of penis due to Peyronie disease
...
Plaque
Corpus cavernosum (spongy bodies)
Corpus spongiosum


F I G U R E 2 4 - 1 2
A punch biopsy is used for deeper lesions and the area may require closure
Introduction
...
...
Introduction codes (54200-54250) report various injection procedures, irrigations, plethysmography, and other tests
An example would be an injection procedure for Peyronie disease in which steroids are injected into the fibrous tissue of the penis to decrease pain, deformity, and fibrous tissue size
...
There are two ways the fibrous tissue can be injected: the first way is to inject steroids directly into the area of the lump formed by the fibrous tissue (54200), and the second way is to expose the fibrous tissue through an incision and then inject steroids into the fibrous tissue (54205)
...
Priapism is a state of prolonged erection that can last from hours to days because of the inability of the blood to flow from the penis, which returns the penis to a flaccid state
...
The condition may be caused by medications used to treat impotence, such as sildenafil citrate (Viagra) or medical conditions, such as leukemia, multiple myeloma, or tumor infiltrate
...
If medical intervention is necessary, the surgeon introduces a large needle into the corpus cavernosum and aspirates blood, which is keeping the penis erect
...
The corpus cavernosum is then irrigated with a saline solution
...
The entire procedure is reported with 54220
...
Repair
...
...
Repair category (54300-54440) codes are for various repairs made to the penis
The code descriptions often state the condition for which the procedure is being performed
...
For example, 54304 is plastic repair for correction of chordee or a first-stage hypospadias (defined in next paragraph) repair, and 54380 is plastic repair for epispadias
...
Many other codes also indicate the stage of the procedure
...
Many of the Repair codes refer to repair of chordee and hypospadias
...
Chordee is a condition in which the penis has a ventral (downward) curve and is a congenital deformity
...
Hypospadias is a congenital abnormality in which the urethral meatus (opening) is abnormally placed, usually along the ventral aspect (underside) of the shaft
...
Degrees of hypospadias are classified according to location: anterior, middle, or posterior
...
Hypospadias may lead to chordee
...
The farther from the glans penis the opening is, the greater the chordee
...
Read the code descriptions for Repair codes carefully as many of the descriptions have only slight differences
...
Codes in the range 54400-54417 report insertion, repair, or removal of various types of penile prostheses
...
The codes are divided based on the type of service and often on the circumstances of the service
...
Erectile dysfunction (impotence) is a condition in which the penis does not become erect
...
Impotence may be caused by a variety of conditions, such as obesity, chronic illness, or as a result of medication
...
One surgical solution to impotence is insertion of a penile implant
...
There are various types of penile implants, but mainly there are two broad categories: non-inflatable (malleable or semi-rigid, 54400) and inflatable (54401)
...
These implants are inserted deep within the penile tissue
...
If the implant is subsequently removed, the removal procedure is reported with 54406 (inflatable) or 54115 (non-inflatable)
...
On occasion, removal and replacement are accomplished during the same operative session
...
Removal of a previously placed prosthesis with insertion of a new prosthesis during the same operative session is reported with 54410, 54411 (inflatable), or 54416/54417 (non-inflatable)
...
Testis

Excision
...
The Excision category (54500-54535) codes report services such as biopsy, excision, orchiectomy, and exploration of the testis
...
Biopsies may be percutaneous (54500) or incisional (54505)
...
If an incisional biopsy of the testis is performed bilaterally, report modifier -50 with 54505
...
Extraparenchymal is defined as unrelated to the essential elements of an organ
...
Removal of an extraparenchymal lesion of the testis is reported with 54512
...
An incision is made on the scrotum, and the testicle is pulled out through the incision where the tunica vaginalis is opened and the lesion is removed
...
The testicle is returned to the scrotum and the area is sutured closed
...
An orchiectomy is the removal of a testis
...
CPT codes 54520-54535 report orchiectomies based on if the procedure was simple/radical, unilateral/bilateral, with/without testicular prosthesis insertion, and the approach used to gain access to the site
...
Watch for codes that specify unilateral or bilateral
...
For example, a simple orchiectomy with or without testicular prosthesis insertion (54520) reports a unilateral procedure
...
When the procedure is bilateral, modifier -50 must be added to correctly report the procedure
...
Exploration, Repair, and Laparoscopy
...
...
Undescended testis (cryptorchidism) is a congenital condition in which the testis(es) did not descend into the scrotal sac
The condition may be unilateral or bilateral
...
The testis(es) may remain in the abdominal, inguinal, or prescrotal areas or may move back and forth between areas
...
Often, undescended testis is associated with a hernia, and if this was the case, during the hernia repair procedure, the undescended testis is brought down into the scrotum and anchored with sutures (orchiopexy)
...
An exploration may be necessary to locate the undescended testis(es), and the choice of codes (54550, 54560) is determined based on the approach used (inguinal/scrotal or abdominal) to gain access to the area
...
The exploration codes report a unilateral procedure, so if a bilateral procedure was performed, add modifier -50
...
During an exploration, when no more definitive procedure is performed, it is only reported as an exploration
...
If the testis was located during the exploration and the surgeon moved the testis into the scrotal sac, the procedure is no longer an exploration but a corrective procedure (orchiopexy)
...
An orchiopexy is reported with codes from the Repair category or the Laparoscopy category, depending on the technique used
...
An orchiopexy in which the operative site is opened to the surgeon's view is reported with 54640 or 54650, depending on whether the approach was inguinal or abdominal
...
If the orchiopexy is performed laparoscopically, report the procedure with 54692
...
The following testes code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:
54500-54535
Excision
54550-54560 Exploration
54640-54680 Repair
54690-54692 Laparoscopy
The third-party payer may require the use of -RT and/or -LT rather than modifier -50
Epididymis
The epididymis is a narrow, coiled tube located on the top of the testes that connects the efferent ducts at the back of each testicle to the vas deferens
...
The epididymis is divided into the caput (head), corpus (body), and cauda (tail)
...
The epididymis can become infected, inflamed, or obstructed
...
When an abscess or hematoma forms in the epididymis, the surgeon may incise and drain the area (54700)
...
At times, the testis, scrotal space, and epididymis are the site of abscess or hematoma
...
When any or all of these areas are incised and drained, the service is reported with 54700
...
For example, if the surgeon incised and drained the scrotal space, the service is reported with 54700
...
Or, if the surgeon incised and drained the testis, scrotal space, and epididymis, the service is reported with 54700
...
The one code reports incision and drainage of each or all of the areas
...
Excision
...
...
The Excision category (54800-54861) of the Epididymis codes reports biopsy, exploration (with/without biopsy), lesion or spermatocele excision, and unilateral or bilateral removal
A spermatocele is a cyst that contains sperm, and during the excision of the cyst the epididymis may or may not be removed depending on the damage to the area caused by the presence of the cyst
...
Code 54840 reports the excision of a spermatocele with or without an epididymectomy
...
Repair
...
...
Repair to the epididymis is an epididymovasostomy
During epididymovasostomy, the epididymis is connected to the vas deferens
...
The surgical procedure is reported with 54900 or 54901, depending if the procedure was unilateral or bilateral
...
An operating microscope is often used during this procedure and reported separately with 69990
...
The following epididymis codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:
54700 Incision
54800-54840 Excision
54865 Exploration

The third-party payer may require the use of -RT and/or -LT rather than modifier -50
...
Tunica Vaginalis
Incision and Excision
...
...
The tunica vaginalis is a serous sheath of the testis, which can be the site of a hydrocele (fluid collection)
The physician may aspirate the fluid or inject a substance such as a sclerosing agent (55000) to help prevent further accumulation of fluid
...
Another method of management of a hydrocele is excision (unilateral, 55040 or bilateral, 55041), which may be accompanied by a hernia repair that is reported separately (49495-49501)
...
Repair
...
...
A Bottle type repair (55060) is a surgical procedure performed to remedy a hydrocele of the tunica vaginalis
An incision is made in the inguinal or scrotal area, and the hydrocele is drained and repositioned
...
A catheter may be left in place to ensure continued drainage of the area and to prevent further fluid accumulation
...
Scrotum

Incision
...
...
The scrotum is the sac that contains the testes
If a lesion of the skin of the scrotum is removed, assign codes from the Integumentary System to report the service
...
However, if the abscess is in the scrotal wall and requires drainage, report the procedure with 55100 (Drainage of scrotal wall abscess)
...
If the abscess is of the epididymis, testis, and/or scrotal space, report the service with 54700 because the code reports procedures to any of the three areas
...
Repair
...
...
Scrotoplasty (also known as oscheoplasty) is repair of a congenital abnormality or traumatic defect of the scrotum
Skin flaps may be utilized during a simple repair (55175) and in the more complex repair (55180) rotational pedicle grafts and/or free skin grafts may be used
...
Simple skin flaps are included in the scrotoplasty and not reported separately, but the more complex grafts are reported in addition to the scrotoplasty
...
Vas Deferens
Incision
...
The vas deferens is the tube that carries sperm from the testes to the ejaculatory duct and the urethra
...
A vasotomy (55200) is cutting into the vas deferens
...
Usually the procedure is performed to obtain a semen sample or to determine if there is obstruction
...
Code 55200 includes cannulization of the vas deferens
...
The code describes a unilateral or bilateral procedure, so there is no need to report modifier -50 with this code
...
Excision
...
...
A vasectomy (55250) is a procedure in which a section of the vas deferens is removed for purposes of sterilization
A small incision is made on the scrotum, and the vas deferens is identified and brought out through the incision
...
A section of the vas deferens tube is cut and tied, stitched or sealed, and the vas deferens is returned to its natural position
...
The procedure includes a unilateral or bilateral procedure and postoperative semen examination(s)
...
The semen is examined at intervals after sterilization to ensure the procedure was a success
...
Introduction
...
...
A vasotomy (55300) may also be performed for a vasogram, seminal vesiculogram, or epididymogram in which colored dye is traced through the vas deferens to visualize any obstruction
The radiological supervision/interpretation is reported separately with 74440
...
When a vastomy is combined with a testis biopsy, report 54505-51
...
Repair
...
...
A vasovasostomy or vasovasorrhaphy is a procedure to remove obstruction from the vas deferens or for a vasectomy reversal
Injection of dye is used during the procedure to identify the area of blockage
...
Once the area is identified, it is removed, and the ends of the vas deferens are anastomosed (reconnected end to end)
...
Semen sampling may be conducted to ensure the removal of the blockage
...
Code 55400 reports a unilateral procedure
...
modifier -50 should be added to indicate a bilateral procedure
...
An operating microscope is often used during the procedure and is reported separately with 69990
...
...
Spermatic Cord

Excision and Laparoscopy
...
The spermatic cord is a collection of structures that suspends the testes in the scrotum as illustrated in Fig
24-13
...
The spermatic cord may be the site of formation of a hydrocele, lesion, or varicocele
...
Unilateral excision of a spermatic cord hydrocele is reported with 55500 with modifier -50 added to report a bilateral procedure
...
A varicocele is a mass of enlarged vessels that occurs when the valves that control blood flow in and out of the vessel become defective, and the blood is not able to circulate out of the vessel
...
The trapped blood causes the vessel to swell
...
Excision of a varicocele by means of a scrotal approach is reported with 55530, and an abdominal approach with 55535
...
A hernia repair may be performed during the same operative session, and with other procedures in this subsection have been reported separately
...
However, the single code 55540 reports both the varicocele excision and a hernia repair
...
If the varicocele is repaired using surgical laparoscopy, report the procedure with 55550
...
The following spermatic cord code range is unilateral and requires modifier -50 if the procedure was performed bilaterally:

55500-55550
Spermatic cord (Excision and Laparoscopy categories)
The third-party payer may require the use of -RT and/or -LT rather than modifier -50
FIGURE
24-13 Spermatic cord
Spermatic cord
Cremasteric muscle & fascia
Vas deferens
Epididymis
Testis (covered by visceral layer of tunica vaginalis)



Seminal Vesicles

The seminal vesicles are a pair of glands located posterior to (behind) the bladder
...
The glands provide the majority of the fluid that becomes semen and empties into the ejaculatory ducts and the urethra
...
Seminal vesicles codes are located in the 55600-55680 range
...
Incision
...
...
A vesiculotomy is surgical cutting into the seminal vesicles
The approach can be by an incision into the lower abdomen or the perineum (between the anus and scrotum)
...
Frequently, the procedure is performed to relieve pressure due to inflammation
...
There are two codes to report a vesiculotomy based on the extent of the dissection required to accomplish the procedure
...
If the procedure required simple dissection, report 55600, and if complicated dissection was required, report 55605
...
The codes are unilateral, so a bilateral procedure requires modifier -50
...
Excision
...
A vesiculectomy is the removal of one of the seminal vesicles
...
The procedure is performed to remove a tumor, calculus (stone), or other obstruction
...
The approach may be through the lower abdomen or perineum, but the choice of codes is the same (55650) because the code description indicates "vesiculectomy, any approach
...
" The code reports a unilateral procedure, so modifier -50 is required for a bilateral procedure
...
The Mullerian ducts develop prenatally in females, and the Wolffian ducts degenerate
...
In males it is the opposite, the Wolffian ducts develop, and the Mullerian ducts degenerate
...
The Mullerian system develops into oviduct, uterus, and upper vagina
...
The Wolffian ducts develop into epididymis, vas deferens, and seminal vesicles
...
In some males a remnant of the Mullerian duct remains and a cyst may form at that site
...
The cyst may be excised using a lower abdominal or perineal approach and reported with 55680
...
Prostate
The most common conditions involving the prostate are inflammation (prostatitis), benign enlargement (BPH, benign prostatic hypertrophy), and cancer
...
Prostate cancer is the most common type of cancer in men
...
Benign Prostatic Hyperplasia and Prostatectomy
...
...
The symptoms of BPH are urinary frequency, nocturia, urgency, decreased force of urine stream, and the feeling that the bladder has not completely emptied
These symptoms are a result of the excess prostate tissue pressing against the urethra and bladder
...
Treatment for BPH is based on the degree of prostate enlargement and severity of symptoms
...
Minimally invasive treatments include balloon dilation, prostatic stents, and thermal-based therapies
...
If these treatments are not successful, surgical intervention may be necessary, such as coagulation, transurethral resection, laser vaporization, or open surgical procedure
...
BPH treatment and prostatectomy procedures are reported with codes from both the Urinary System and/or the Male Genital System
...
Prostatic stents (52282 [permanent], 53855 [temporary]) are flexible metal mesh tubes designed to be inserted into the urethra at the level of the prostate and expanded after placement
...
The stent keeps the urethra open
...
Over time, the urothelial tissue grows over the stent and the stent becomes incorporated into the urethral wall
...
Transurethral microwave heat treatment (TUMT, 53850) is the use of microwaves that are sent through a catheter and introduced into the urethra to coagulate excess prostate tissue and allow the urethra to be less constricted
...
Transurethral needle ablation (TUNA, 53852) is a procedure that utilizes radiofrequency to create heat that is applied to the prostate to destroy excess prostate tissue
...
During this procedure the urethra is punctured to allow the needles to be placed directly into the prostate
...
The needles are insulated, so the urethra is not damaged when pierced
...
For some patients these less radical treatments are not effective or advisable
...
For example, for patients with renal insufficiency, recurrent gross hematuria, or bladder stones because of BPH, a surgical procedure is the recommended treatment option
...
Surgical therapies include transurethral prostate incision, electrovaporization, and laser ablation/coagulation
...
Let's take a closer look at each of these surgical options:

Transurethral resection of the prostate (TURP, 52601, 52630) is the gold-standard of surgical procedures for removal of tumor or prostatic tissue
...
A special type of cystoscope is inserted through the urethra
...
The scope has lights, valves for controlling irrigation fluids, and an electrical loop to remove tissue and/or obstructions and cauterize blood vessels
...
Transurethral incision of the prostate (TUIP, 52450) is used when the prostate is only slightly enlarged
...
Two incisions are made in the prostate to relieve the pressure on the urethra without removing tissue
...
When a laser is used to accomplish the prostatectomy, the choice of codes is first based on whether the procedure was a coagulation (52647) or vaporization (52648)
...
Code 52648 includes with or without transurethral resection of the prostate
...
LASER COAGULATION (52647)
n
Transurethral ultrasound-guided laser induced prostatectomy (TULIP, non-contact) is a procedure in which a laser is used to coagulate prostate tissue
There is no direct visualization of the prostate using this method, and the penetration is not as deep as with other more commonly performed methods
...
n
Visual laser of the prostate (VLAP, non-contact) is under the direct vision of the surgeon, but the laser fiber does not come in direct contact with the prostate
This method coagulates the tissue rather than vaporizing it
...
Once coagulated, the tissue dies and is sloughed off, which relieves the pressure
...
n
Interstitial laser coagulation of prostate (ILCP, contact) uses several laser fibers that are placed directly into the prostate to coagulate the tissue
There is no direct visualization with the ILCP
...
LASER VAPORIZATION (52648)
n
Transurethral vaporization of the prostate (TUVP or TVP, contact) uses electrical current to vaporize tissue of the prostate by means of a ball that is rolled over the tissue
The ball contains a current that vaporizes the tissue
...
This procedure is a modification of a TURP
...
LASER VAPORIZATION WITH/WITHOUT RESECTION (52648)
n
Holmium laser enucleation of the prostate (HoLEP, contact), also known as transurethral holmium laser resection (THLR), is a procedure used to resect prostate tissue by means of a holmium laser fiber
There is less intraoperative bleeding with this procedure than with a TURP
...
There are many different techniques used to remove the prostate (prostatectomy)
...
Codes in the Excision category (55801-55865) represent open surgical procedures
...
Determination of the correct code to report a prostatectomy (removal of the prostate) is based first on the approach (perineal, suprapubic, or retropubic)
...
n
Perineal approach is through the space between the rectum and the base of the scrotum and is used to gain access to a prostate that is located closer to the perineal area
n
Suprapubic approach is through the lower abdominal region, and it is used to gain access to the front (anterior) surface of the bladder
The access to the prostate is gained by an opening in the bladder neck
...
n
Retropubic approach is also through the lower abdominal region and is used to gain access to the front (anterior) of the prostate
Once the correct approach has been identified, the extent of the procedure will determine code selection
...
The term "subtotal" used in many of the code descriptions means anything less than the total removal of the prostate, and the term "radical" means total removal of the prostate
...
Codes 55812-55815 and 55842-55845 include code selection based on the lymph node biopsy/removal performed
...
If lymph node biopsy (single or multiple) and limited removal of pelvic lymph node(s) was performed, report 55812 (perineal approach) or 55842 (retropubic approach)
...
If lymph nodes were removed bilaterally and include the external iliac, hypogastric and obturator nodes, report 55815 (perineal approach) or 55845 (retropubic approach)
...
A laparoscopic retropubic prostatectomy (LRP, 55866) is a minimally invasive procedure that may be utilized instead of an open procedure
...
Robotic assisted prostatectomy (RAP) is a new instrumentation used with LRP and is designed to assist in the performance of some surgical tasks
...
Several small incisions are made through which robotic instrumentation is inserted
...
The surgeon operates the instrumentation from a console
...
The use of RAP necessitates an assistant during surgery
...
Surgeons who use a RAP system are extensively trained by the manufacturer of the system before using the system during surgery
...
The new robotic systems enhance the precision with which the procedure can be performed
...
Now that you have reviewed BPH treatment and prostatectomies, let's review the remaining codes in the Prostate category
...
Biopsy
...
...
Biopsy of the prostate may be performed with a needle, punch, or by incision
Report a prostate biopsy with 55700 (needle, punch), 55705 (incisional), or 55706 (transperineal, stereotactic)
...
Do not report these codes during the same procedure
...
For example, if, during the same operative session, a needle or punch biopsy of the prostate (55700) is undertaken, and it is followed by an incisional biopsy (55705) either to supplement or to obtain adequate tissue, the appropriate CPT code to report is 55705, not both codes
...
Do not confuse a prostate biopsy with a fine needle aspiration (FNA)
...
During an FNA, fluid is withdrawn for analysis and is reported with 10021 or 10022
...
A prostatotomy is an incision into the prostate
...
Codes 55720 and 55725 describe prostatotomies performed to drain an abscess
...
The surgeon inserts a needle into the prostate via the perineum or through the rectum
...
Reporting of the procedure is based on if the procedure was simple or complicated
...
A complicated prostatotomy would document excess bleeding or other factors that increase time and effort necessary to complete the service
...
Brachytherapy
...
...
Brachytherapy (55860-55865) is a type of radiation treatment for prostate cancer and utilizes high dose rate (HDR, temporary method) or low dose (permanent seeds) and may be used in combination with biopsy/removal of lymph nodes (Fig
24-14)
...
The placement of the brachytherapy element(s) can be accomplished by transperineal placement (through the area between scrotum and anus) or with open exposure of the prostate
...
The transperineal placement involves the fastening of a template to the perineal area
...
The template contains a pattern of holes that indicate where the catheters or needles are to be placed to correctly access the area around the prostate
...
Approximately 100 permanent seeds are placed for the low-dose method
...
For the high-dose method of temporary delivery, small catheters are placed into the prostate, and a series of radiation treatments are delivered
...
For example, a patient would present to an outpatient department of the hospital where a template would be fastened to the perineal area
...
The catheters would be inserted through the holes in the template into the prostate
...
The treatment plan is established by the radiation oncologist, and the computer that is attached to the catheters is set to deliver the prescribed dose of radiation
...
If the prescribed dose cannot be administered in one session, the catheters remain in place, and the patient remains in the hospital overnight
...
The next day, the patient would receive another radiation treatment
...
The catheters would be removed, and the patient would be discharged from the hospital
...
An advantage of the HDR is that the physician can regulate the radiation dosage more precisely than with the low-dose method
...
The transperineal placement is reported by the surgeon or urologist with 55875 and includes the use of a cystoscope if applicable
...
The placement of the radioelements is reported separately by the radiation oncologist with 77776-77778
...
If ultrasound guidance is used during the placement, the guidance is reported separately with 76965, ultrasonic guidance for interstitial radioelement application
...
Another approach for placement of radioactive substances is the open approach in which the prostate is viewed by the surgeon
...
The exposure procedure is reported by the surgeon or urologist with 55860, and the application of the radioelements is reported by the radiation oncologist with 77776-77778, based on the number of sources placed: simple (1-4), intermediate (5-10), complex (10)
...
During the same operative session in which the radioelements are placed, the surgeon may biopsy lymph nodes and/or may perform a lymphadenectomy (55862)
...
If a bilateral pelvic lymphadenectomy is performed and includes the external iliac, hypogastric, and obturator nodes, the procedure is reported with 55865
...
Transrectal ultrasound (TRU, 76872) is guidance that is often used when reporting biopsy, evaluation and staging for prostate cancer, delivery of brachytherapy, evaluation or aspiration of prostate abscess, evaluation of infertility, diagnosis of prostate abnormalities, and monitoring of treatment response
...
INTRO TO CPT CODING
BOOK II


Surgery: Urinary System
Section Objectives
Understand the reporting procedures in the Urinary System subsection
Understand the various endoscopic procedures performed in the Urinary System
The Urinary System subsection of the CPT codebook (50010-53899)contains codes for reporting procedures of the kidneys, ureters, bladder, and urethra
...
Generally, under each anatomic heading, codes can be found for reporting procedures involving incision, excision, introduction, repair, and endoscopy procedures
...
Procedures and guidelines associated with reporting renal pelvis catheter procedures, endoscopy procedures, and prostate procedures are detailed below
...
(See Figure 4-79
...
)
Renal Pelvis Catheter Procedures
Renal pelvic catheter procedures are most often performed for the treatment of ureteral strictures and obstructions
...
They are differentiated by approach (percutaneous and transurethral) and type (internally dwelling and externally dwelling)
...
When the drainage of a renal abscess (50020) is performed, an incision is made to the abscess cavity, and the site is irrigated and drained
...
(See Figure 4-80
...
) When a nephrolithotomy is performed with calculus removal (50060-50075), a kidney stone (calculus) is removed by an incision in the kidney
...
Use 50070 if complicated by a congenital kidney abnormality
...
(See Figure 4-81
...
) Use codes 50382-50389 to report the removal of ureteral stents
...
Ureteral stents are thin catheters threaded into the ureter for diversion of the urine either internally into the bladder or externally into a collection system
...
These stents must be monitored while in place and removed when no longer needed
...
They are required to be periodically changed, especially when they are chronically indwelling
...
Code 50382 is used to report a percutaneous approach for the removal and replacement of an internally dwelling ureteral stent
...
This capture approach uses a threadlike element at the end that forms a loop and is used to snare and extract the stent from the bladder
...
Code 50384 is reported only for removal of ureteral stent via percutaneous approach
...
Code 50387 is reported for removal and replacement of an externally accessible ureteral stent via the transnephric approach
...
As indicated in the parenthetical instructions following these three codes, for bilateral procedure, append the modifier 50
...
Code 50389 is reported for those instances in which a ureteral stent has been placed with the loops in the renal pelvis and urinary bladder
...
Following clearance of blood after the stent placement, the nephrostomy catheter removal is performed under fluoroscopic guidance
...
When performing the introduction of a catheter into the renal pelvis (50392), the physician inserts a catheter into the renal pelvis in order to drain urine and/or give an injection
...
See Figure 4-82
...
Code 50395 is reported for the introduction of a guide into the renal pelvis and/or ureter with dilation to establish a nephrostomy tract, percutaneously (see Figure 4-83)
...
FIGURE 4-79 Urinary System

FIGURE 4-80 Drainage of Renal Abscess

FIGURE 4-81 Nephrolithotomy with Calculus Removal


• Ureteral stents

Ureteral stents: Thin catheters threaded into the ureter for diversion of the urine either internally into the bladder or externally into a collection system
...
FIGURE 4-82 Introduction of Catheter into Renal Pelvis

FIGURE 4-83 Percutaneous Nephrostolitotomy or Pyelostolithotomy


The removal of a nephrostomy tube not requiring fluoroscopic guidance is considered inherent to the E/M service
...
Report the appropriate level of E/M service provided
...
1
...
Codes 50382, 50384, and 50387 are unilateral procedures
...
Is it appropriate to append modifier 50 if a bilateral procedure is performed?
When performing a laparoscopic radical nephrectomy (50545), the radical nephrectomy includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy
...
(See Figure 4-84
...
) When performing a laparoscopic nephrectomy (50546), a kidney is dissected and removed under laparoscopic guidance
...
(See Figure 4-85
...
)
When lithotripsy (50590) is performed, the physician breaks up a kidney stone (calculus) by directing shock waves through a liquid surrounding the patient
...
(See Figure 4-86
...
)
FIGURE 4-84 Laparoscopic Radical Nephrectomy

Ureter
With the indwelling of a ureteral stent procedure (50605), the physician makes an incision in the ureter (ureterotomy) and inserts a stent
...
(See Figure 4-87
...
) For placement using cystourethroscopic technique, use 52332
...
When a ureteroileal conduit procedure (50820) is performed, the ureters are connected to a segment of intestine to divert urine flow through an opening in the skin
...
(See Figure 4-88
...
) The laparoscopic ureteroneocystostomy with cystoscopy and ureteral stent placement is reported with code 50947
...
(See Figure 4-89
...
)
FIGURE 4-85 Laparoscopic Nephrectomy

FIGURE 4-86 Lithotripsy

Bladder
The measurement of postvoiding is reported with code 51798, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
...
(See Figure 4-90
...
)
When a laparoscopic sling suspension for urinary incontinence is performed (51990), nonabsorbable sutures are placed laparoscopically into the endopelvic fascia at the bladder neck region on each side and secured to the ipsilateral pectineal ligament
...
The sutures are tied using extra vaginal-urethral knots so as to create a hammock-type suspension of the bladder neck, without urethral occlusion
...
(See Figure 4-91
...
)
FIGURE 4-87 Indwelling Ureteral Stent

FIGURE 4-88 Ureteroileal Conduit

FIGURE 4-89 Laparoscopic Ureteroneocystostomy

FIGURE 4-90 Measurement of Postvoiding

When a cystourethroscopy is performed with ureteral catheterization (52005), a cystourethroscope is passed through the urethra and bladder in order to view the urinary collecting system
...
(See Figure 4-92
...
)
Endoscopy Procedures
Some of the most frequently used procedures listed in the Urinary System subsection of the CPT codebook are endoscopic, including the use of:
FIGURE 4-91 Laparoscopic Sling Suspension for Urinary Incontinence

FIGURE 4-92 Cystourethroscopy with Ureteral Catheterization


Cystoscopy,
Urethroscopy,
Cystourethroscopy,
Ureteroscopy,
Pyeloscopy, and
Renal endoscopy
...
An endoscopy can be used as a diagnostic tool performed before proceeding with a more intensive surgical procedure or to check on the progress, completion, or a complication during the surgical procedure
...
CPT descriptors indicate whether an endoscopic procedure is included in the surgical procedure
...
An example of the use of cystourethroscopy before, during, or after a urological procedure is a sling operation for stress incontinence (57288)
...
There are times, however, when one endoscopic procedure must be performed before a more extensive endoscopic procedure because of anatomic locations
...
In this case, modifier 51 is appended to indicate that multiple procedures were performed at the same session by the same provider
...
Multiple endoscopic procedures performed at the same session by the same provider can be separately reported
...
A patient presented for a cystourethroscopy and removal of a calculus located in the ureter
...
However, to remove the calculus, the urethral stricture must be dilated to provide access
...
Codes 52352, Cystourethroscopy, with ureteroscopy and/or pyeloscopy
...
with removal or manipulation of calculus (ureteral catheterization is included), and 52281 51, Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female, are reported
...
Laterality
Cystourethroscopy codes that are inherently unilateral are 52005, 52007, and 52320-52355
...
When unilateral procedures are performed bilaterally, modifier 50 should be appended to the appropriate code(s)
...
(For Medicare purposes only, code 52005 is inherently bilateral
...
therefore, modifier 50 is not appended to code 52005 for Medicare reporting
...
When code 52005 is reported for non-Medicare purposes, modifier 50 should be appended for bilateral procedures
...
)
Cystourethroscopy codes that should never be reported with modifier 50 are 52000, 52010, 52204-52285, and 52305-52318
...
Code 52351 is not routinely reported with codes 52341-52346 and 52352-52355, as it describes a diagnostic cystourethroscopy when performed on the same side
...
However, there are instances when a diagnostic cystourethroscopy and a procedure described by a code from the 52341-52346 or 52352-52355 series are performed on contralateral (opposite) sides of the body
...
When these are performed, code 52351 is reported separately with modifier 59, Distinct procedural service, appended
...
Prostate Procedures
Codes in the 52450-52700 series are used to report transurethral procedures of the vesical neck and prostate
...
Codes 53850-53853 are also used to report transurethral destruction of prostatic tissue
...
Code 52601 is used to report a procedure commonly referred to as TURP (transurethral resection of the prostate)
...
This procedure uses electrical current to heat a wire loop on a resectoscope that slices through urethral or prostatic tissue like a knife
...
Two settings exist to regulate the current: high-voltage current is used to cut the tissue and low-voltage current to coagulate the bleeding
...
As indicated in the code descriptor, when code 52601 is reported, vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included, when performed, and not reported separately
...
This code is intended to describe an initial resection of the prostate as well as a complete TURP
...
(See Figure 4-93
...
)
FIGURE 4-93 Transurethral Resection of Prostate, Complete

Prostate resection can be performed in two stages
...
Code 52612 is used to report the first stage of a two-stage resection
...
Code 52614 describes the second stage of a two-stage resection procedure and is reported when the resection is completed
...
Other procedures involving the prostate include:

Laser coagulation (52647),
Laser vaporization (52648),
Transurethral destruction of prostate tissue by microwave thermotherapy (53850),
Transurethral destruction of prostate tissue by radiofrequency thermotherapy (53852), and
Transurethral destruction of prostate tissue by water-induced thermotherapy (53853)
...
Code 52647 describes laser coagulation of the prostate
...
This code is intended to describe laser procedures that primarily heat the prostate and require sloughing for the treatment to be complete
...
This code is reported even if an incision or small amount of vaporization is done in combination with the coagulation
...
In this case, it is not appropriate to separately report code 52648 for the small amount of vaporization performed
...
Code 52648 describes laser vaporization with or without transurethral resection of the prostate
...
Vaporization is usually accomplished by moving a laser tip across the surface of the prostate, causing immediate vaporization of tissue and an end result that looks like a cavity (similar to the effect of a TURP)
...
(See Figure 4-94
...
)
FIGURE 4-94 Contact Laser Vaporization of Prostate


2
...
When code 52601 is reported, would it be appropriate to report vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy separately?

• Transurethral resection of the prostate (TURP)
• Transurethral microwave thermotherapy
Code 53850 describes transurethral microwave thermotherapy, which is the selective destruction of prostate cells by therapeutic levels of heating
...
Transurethral microwave thermotherapy is a process of delivering sufficient microwave heating to destroy prostatic tissue without causing unnecessary damage to surrounding structures
...
The technique combines the principles of microwave radiative heating and conductive cooling to destroy tissue deep within the prostate while preserving surrounding structures such as the bladder neck, urethral mucosa, and distal sphincter
...
Code 53852 describes transurethral destruction by radiofrequency thermotherapy, where low-power radiofrequency energy is used to cause tissue ablation and coagulation of prostate tissue
...
Insulated needles are pierced through the prostatic urethra to deliver radiofrequency energy directly into the prostate while the insulation on the needles protects the urethra
...
This procedure creates areas of necrosis within the prostate while preserving the urethral tissue
...
Code 53853 describes transurethral destruction of prostate tissue by water-induced thermotherapy, where water is heated outside the body and circulated through the prostate in heat-shielded catheters
...
only the balloon emits heat
...
At 60°C, coagulative necrosis of the prostatic tissue occurs to an average depth of 1
...
0 cm from the urethra
...
Because water is heated and pumped from outside the body, there is no need to use internal temperature probes as is necessary with benign prostatic hypertrophy treatments such as microwave (53850) and radiofrequency-based (53852) procedures
...
When a temporary prostatic urethral stent is inserted, it is reported with code 53855
...
(See Figure 4-95
...
)
FIGURE 4-95 Temporary Prostatic Urethral Stent Insertion


Transurethral resection of the prostate (TURP): A procedure that uses electrical current to heat a wire loop on a resectoscope that slices through urethral or prostatic tissue like a knife
...
Transurethral microwave thermotherapy: The process of delivering sufficient microwave heating to destroy prostatic tissue without causing unnecessary damage to surrounding structures
...
1
...
Yes
...
It would be appropriate to append modifier 50 to codes 50382, 50384, and 50387 if a bilateral procedure is performed
...
2
...
No
...
Vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included, when performed, and not reported separately
...
BOOK II COMPLETED




PRINCIPLES OF COPT CODING
BOOK III


Urinary System
The Urinary System subsection of the CPT code set contains codes for reporting procedures of the kidney, ureter, bladder, and urethra (see Figure 4-51)
...
Generally, under each anatomic heading, codes can be found for reporting procedures involving incision, excision, introduction, repair, and endoscopy procedures
...
This section contains discussion of some of the procedures and guidelines associated with reporting renal transplantation, lithotripsy, renal tumor ablation, laparoscopy procedures, bladder catheter insertion, urodynamics, endoscopy procedures, and prostate procedures
...
FIGURE 4-51
Urinary System
Renal Transplantation
Codes and guidelines for reporting renal allotransplantation are structured to identify the following three separate components of work performed:
Unilateral or bilateral nephrectomy of a cadaver donor or living donor nephrectomy
Backbench work
Recipient renal allotransplantation
Backbench work is the preparation of the donor organ graft for transplantation to the recipient site
The specific work involved in backbench work is defined in the guidelines
...
This preparation of the graft is performed on a back bench in the operating room, hence the term backbench work
...
Standard backbench work varies on the basis of whether the donor kidney is from a cadaver (50323) or a living donor (50325)
...
The operative report should be carefully reviewed to determine whether the donor organ is from a living or a cadaver donor
...
Additional backbench work to prepare the donor kidney prior to transplantation may include venous, arterial, and/or ureteral anastomosis(es)
...
This additional work is separately reported with a code from 50327 through 50329, as appropriate
...
The work to remove the kidneys for transplant from the donor and the actual transplant into the recipient are reported separately with CPT codes 50300-50320, 50360-50365, and 50547
Renal Pelvis Catheter Stent Procedures
Renal pelvic catheter stent procedures are most often performed for the treatment of ureteral strictures and obstructions
...
They are differentiated by approach (percutaneous and transurethral) and type (internally dwelling and externally dwelling)
...
Codes 50382-50389 are reported for the removal of ureteral stents
...
These procedures are most often performed by interventional radiologists
...
Code 50382 is used to report the removal as well as replacement of an internally dwelling ureteral stent by snare or capture method when performed through a percutaneous transnephric approach
...
This procedure involves removal of an indwelling, entirely internal double-J ureteral stent by snare or capture method
...
Code 50384 is reported for procedures involving only the removal of an internally dwelling ureteral stent by snare or capture method via a new percutaneous transnephric approach (the stent is not replaced)
...
Code 50385 is reported for removal by snare or capture method and replacement of an internally dwelling ureteral stent via a transurethral approach without the use of cystoscopy
...
Code 50386 is reported for removal by snare or capture method of an internally dwelling ureteral stent via a transurethral approach without the use of cystoscopy
...
Removal of a ureteral stent by means of cystoscopy is reported with codes 52310-52315
...
Code 50387 is reported for removal and replacement of an externally accessible (the stent catheter has a portion that lies external to the patient) ureteral stent via the transnephric approach
...
Codes 50382-50387 include the radiological S&I of the procedures
...
Code 50389 is reported for those instances in which a previously placed nephrostomy tube catheter must be removed under fluoroscopic guidance
...
This procedure may be needed for an encrusted nephrostomy tube catheter that is resistant to removal or a damaged nephrostomy tube catheter that may completely fracture during removal (so a safety wire is used to maintain access as the catheter is removed under fluoroscopy)
...
Code 50395 is reported if a new nephrostomy tract is established
...
If percutaneous nephrostolithotomy (PNL) is performed, report code 50080 or 50081, as appropriate, in addition to code 50395 (see Figure 4-52)
...
The parenthetical instruction following codes 50080 and 50081 indicates that the service does not include establishment of a nephrostomy
...
To further clarify, code 50395 is not used for dilation of an existing nephrostomy but rather for the creation of a new nephrostomy tract
...
FIGURE 4-52
Percutaneous Nephrostolithotomy or Pyelostolithotomy
If the radiologist establishes the tract, then he or she should report code 50395, because code 50395 is used to report the access (whereas codes 50080 and 50081 describe the removal of the stone)
The radiological S&I code 74485 is used to report imaging services associated with tract dilatation
...
In this instance, the urologist would report code 50080 or 50081 depending on the size of the stone documented and removed
...
However, should the urologist perform both procedures, codes 50395 and 50080 or 50081, as appropriate, and code 74485 may be reported by the urologist
...
The modifier 26, Professional component, should be appended to code 74485
...
Code 50590 is used to report extracorporeal shockwave lithotripsy (ESWL) of the kidney
...
ESWL uses shockwaves to break up the renal stones
...
As code 50590 is an inherently unilateral code, modifier 50 should be appended when the procedure is performed bilaterally
...
(Refer to Chapter 8 for further discussion of modifier 50
...
)
Renal Tumor Ablation
There are specific codes for renal tumor ablation and ablation of renal cysts, depending on the surgical approach: laparoscopic, open, or percutaneous
...
Code 50541 is used to report the laparoscopic ablation of renal cysts
...
Code 50542 is used to report laparoscopic ablation of renal mass lesion(s) by any method (eg, cryoablation or radiofrequency ablation)
...
This code is reported one time regardless of the number of lesions treated
...
The code for open ablation of renal mass lesion(s), 50250, is specific to cryoablation
...
Tumors treated by nephrectomy are coded by means of the appropriate nephrectomy code (50220-50240, 50543, 50545, 50546, and 50548)
...
(See Figures 4-53 and 4-54
...
) Renal mass lesion(s) ablated by any open method other than cryoablation or treated by nephrectomy, such as open radiofrequency ablation of renal tumor(s), would be reported with the unlisted code 53899
...
Both the laparoscopic, any method and open, cryoablation renal mass lesion(s) codes 50542 and 50250, respectively, include intraoperative ultrasound guidance if performed
...
For renal tumor ablation procedures from a percutaneous approach, there are specific codes based on the method of tumor ablation
...
Code 50592 is used to report percutaneous radiofrequency ablation of renal tumor(s)
...
Code 50593 is used to report percutaneous cryoablation of renal tumor(s)
...
Code 50593 is a unilateral procedure
...
For bilateral procedures, code 50593 should be reported with modifier 50
...
As different modes of imaging may be used depending on the patient's specific clinical circumstances, imaging for the guidance and monitoring of the percutaneous renal tumor ablation procedure is separately reported
...
The modality-specific imaging codes for the guidance and for monitoring of ablation are 76940, 77013, and 77022 (ultrasound, CT, and MRI, respectively)
...
Percutaneous renal tumor ablation is an inherently unilateral code
...
Therefore, modifier 50 should be appended when the procedure is performed bilaterally
...
FIGURE 4-53
Nephrectomy, Including Partial Ureterectomy

FIGURE 4-54
Partial Nephrectomy
Insertion of Bladder Catheter
Codes 51701-51703 are used to report insertion of bladder catheters
Code 51701 differs from codes 51702 and 51703 in that it describes the insertion of a straight bladder catheter used for intermittent catheterization, catheterization to obtain postvoid residual urine or to obtain a clean-catch urine specimen, after which the catheter is removed
...
Codes 51702 and 51703 are used to report the insertion of a temporary indwelling bladder catheter, which remains in place for a period of time
...
Endoscopic Procedures
Some of the most frequently used procedures listed in the Urinary System subsection of the CPT code set are endoscopic, including the use of cystoscopy, urethroscopy, cystourethroscopy, ureteroscopy, pyeloscopy, and renal endoscopy
...
Endoscopy can be used as a diagnostic tool performed before proceeding with a more intensive surgical procedure or to check on the progress, completion, or a complication during the surgical procedure
...
CPT descriptors will indicate whether an endoscopic procedure is included in the surgical procedure
...
Examples of the use of cystourethroscopy before, during, or after a urologic procedure are a sling operation for stress incontinence as reported using code 57288, or transperineal placement of needles or catheters into the prostate as reported using code 55875
...
If cystourethroscopy is used to verify surgical placement, it is not separately reported
...
If medically necessary, under certain circumstances, it may be separately reported
...
There are times, however, when one endoscopic procedure must be performed before a more extensive endoscopic procedure due to anatomical locations
...
In this case, modifier 51 would be appended to indicate that multiple procedures were performed at the same session by the same provider
...
(Refer to Chapter 8 for further discussion of modifier 51
...
)
Consider the following example:
EXAMPLE
A patient presents for a cystourethroscopy and removal of a calculus that is located in the ureter
...
However, to enable removal of the calculus, the urethral stricture must be dilated for access to the calculus
...
To accurately reflect these services, the following codes should be reported:
52352
Cystourethroscopy, with ureteroscopy and/ or pyeloscopy
with removal or manipulation of calculus (ureteral catheterization is included)
52281 51
Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female
The CPT codes in this section are also listed with a primary or base code with more extensive codes listed in sequential order or in anatomical order
For example, codes 52351-52355 are used to report cystourethroscopy, with ureteroscopy and/or pyeloscopy, beginning with a diagnostic procedure and ending with a resection of ureteral or renal pelvic tumor
...
However, according to CPT guidelines, a diagnostic endoscopy procedure is included with a therapeutic endoscopy procedure
...
For example, the cystourethroscopy is included in codes 52320-52343, and cystourethroscopy, with ureteroscopy and/or pyeloscopy is included in codes 52344-52346 and 52352-52355
...
In some instances, the main surgical procedure is identified in the CPT descriptor along with minor related procedures that are not reported separately
...
For example, code 52601 is used to report transurethral electrosurgical resection of the prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)
...
The minor procedures indicated in the descriptor may be performed before, during, or after the prostate resection surgery and are not reported separately
...
Laterality of Cystourethroscopy Codes
Cystourethroscopy codes that are inherently unilateral include 52005, 52007, and 52320-52355
...
When unilateral procedures are performed bilaterally, modifier 50 should be appended to the appropriate code(s)
...
(Refer to Chapter 8 for further discussion of modifier 50
...
)
Cystourethroscopy codes that should never be reported with modifier 50 include 52000, 52010, 52204-52285, 52305-52318, and 52402
...
(See Figure 4-55
...
)

FIGURE 4-55
Cystourethroscopy With Biopsy
A careful review of each code descriptor is necessary when selecting the appropriate endoscopy code(s) in order to distinguish the codes for ureteral vs urethral procedures
Also, when multiple endoscopic procedures are performed at the same session by the same provider, it is appropriate to separately report them
...
In this case, modifier 51 would be appended to indicate that multiple procedures were performed at the same session by the same provider
...
(Refer to Chapter 8 for further discussion of modifier 51
...
)
Consider the following example:
EXAMPLE
Dr New performs cystourethroscopy with fulguration and resection of a medium bladder tumor (code 52235)
...
During the same endoscopic session, he also performs a cystourethroscopy with ureteroscopy to treat a ureteral stricture by laser (code 52344)
...
To accurately report his services during that session, Dr New will report the following codes:
52344
Cystourethroscopy with ureteroscopy
with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision)
52235 51
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of
MEDIUM bladder tumor(s) (2
...
0 to 5
...
0 cm)
The code with the highest relative value units should be submitted first with the modifier 51 appended to the second highest procedure
...
Stent Insertion
Codes in the 52320-52355 series include the insertion and removal of a temporary stent during diagnostic or therapeutic cystourethroscopic intervention(s)
...
The insertion of a temporary stent refers to those types of stents that are used during the cystoscopy procedure and removed at the completion of that intervention
...
A temporary stent may be used during a procedure and then removed and replaced with a self-retaining or indwelling stent during the same intervention
...
Codes in the 52320-52355 series, with the exception of code 52332, do not include the placement of a self-retaining or indwelling stent
...
Placement of a self-retaining or indwelling stent is not required in all cases, but when performed via cystourethroscopy, it should be reported separately with code 52332
...
In these cases, code 52332 is reported in addition to the primary procedure(s) performed with modifier 51 appended
...
Code 50605 is used to report a ureteral stent insertion via an open ureterostomy
...
This code is reported when a stent cannot be inserted into the ureter by going up through the bladder (52332 or 50385) nor down through the kidney (50382, 50387 or 50393)
...
In an open ureterotomy, the physician makes an incision in the ureter to insert the stent
...
This procedure is performed in order to restore urine flow when there is an obstruction in the ureter
...
Code 50605 is not reported in conjunction with cystectomy, nephrectomy, or kidney transplant codes
...
CODING TIP Catheters and stents are cylindrical tubes placed in the ureters for distinct purposes
...
Catheters are commonly used to empty the bladder through the urethra, whereas stents are placed in order to restore or maintain urinary flow
...
The insertion and removal of a temporary ureteral catheter (52005) during diagnostic or therapeutic cystourethroscopic with ureteroscopy and/ or pyeloscopy is included in 52320-52355 and should not be reported separately
...
To report insertion of a self-retaining, indwelling stent performed during diagnostic or therapeutic cystourethroscopy with ureteroscopy and/or pyeloscopy, code 52332 is used, in addition to primary procedure(s) performed (52320-52355), and modifier 51 is appended
...
Code 52332 is used to report a unilateral procedure unless otherwise specified
...
It is possible to place indwelling or self-retaining stents in both ureters through the same cystoscope during the same cystourethroscopic diagnostic and/or therapeutic intervention
...
When bilateral ureteral stents are placed, modifier 50 is appended to code 52332
...
In addition, stents may be placed percutaneously without the use of a cystoscope
...
Code 50392 is used to report the initial percutaneous placement of an intracatheter/catheter into the renal pelvis
...
Imaging services provided in conjunction with ureteral stent placement may vary according to the patient's specific clinical circumstances and may be reported with code 74475, 76942, or 77012
...
Code 50393 is used to report the initial percutaneous placement of a ureteral stent through the renal pelvis
...
The RS&I may be reported with codes 74480, 76942, 77002, or 77012
...
CODING TIP Codes 50392 and 50393 are reported for percutaneous access into the kidney performed for both percutaneous nephrostomy placement and ureteral stent placement
...
Unlike the initial placement codes, imaging is specifically an included service for the percutaneous exchange of an internally dwelling ureteral stent (code 50382) and for the exchange of an externally accessible transnephric ureteral stent (code 50387), and therefore imaging guidance would not be reported separately
...
The exchange of an ureterostomy tube or externally accessible ureteral stent via the ileal conduit is reported with code 50688
...
If imaging guidance is performed, code 75984 is additionally reported
...
When bilateral percutaneous ureteral stent services are performed, modifier 50 should be appended
...
The removal procedure may or may not require the use of an endoscope
...
Cystourethroscopy with removal of a self-retaining, indwelling ureteral stent, planned or staged during the associated normal postoperative follow-up period of the original procedure, is reported by means of code 52310 or 52315 with modifier 58 appended, as appropriate
...
(Refer to Chapter 8 or further discussion of modifier 58
...
) If the indwelling stent is inserted via ureterotomy or other procedure that is subject to the surgical package concept, no additional reporting is warranted when the stent is removed during the normal postoperative follow-up period
...
For the removal of an internally dwelling ureteral stent from a percutaneous approach, code 50384 is reported
...
For the percutaneous removal of a nephrostomy tube with concurrent indwelling ureteral stent removal requiring fluoroscopic guidance, code 50389 is reported
...
Both codes 50384 and 50389 include radiological S&I services
...
For the removal (without replacement) of a nephrostomy tube or an externally accessible ureteral stent that does not require fluoroscopic guidance and is not subject to a surgical package, the appropriate level of E/M service provided is reported
...
Urodynamics (51725-51798) are services performed by, or under direct supervision of, a physician or other qualified health care professional and in which all instruments, equipment, fluids, gases, probes, catheters, technician's fees, medications, gloves, trays, tubing, and other sterile supplies be provided by that individual
...
Codes 51727-51729 and 51797 allow reporting of combinations of services that are usually provided together
...
Complex cystometrogram services are interactive examinations between patient and examiner and may vary considerably depending on cystometric findings
...
When fluid is infused into bladder, bladder sensations and bladder volumes are recorded at predefined physiologic landmarks
...
Voiding pressures are monitored and assessed
...
Simple or complex uroflowmetry are reported with codes 51736 and 51741 respectively
...
Electromyography (EMG), of anal or urethral sphincter are reported using codes 51784 (non needled) and 51785 (needle)
...
Measurement of bulbocavernosus reflex latency time can be reported with 51792
...
The use of endoscopy and other instrumentation to treat noncalculus ureteral strictures that may be associated with hydronephrosis is reported by code 52341 or 52344, as appropriate
...
in the ureteropelvic junction by code 52342 or 52345
...
and in the intrarenal area by code 52343 or 52346
...
Codes 52320 and 52352 differ in that these codes are used to report procedures to treat calculous diseases and should be used to describe removal or manipulation of ureteral calculus
...
Codes 52341-52343 are used to report the use of a cystoscope that is passed through the urethra into the bladder to allow visualization of the ureteral orifice for the passage of guide wires to direct balloons or enable other interventions (eg, laser, electrocautery, or incisional devices) in the strictured area
...
Codes 52344-52346 are used to report the use of an ureteroscope passed through the urethra to the bladder and directly into the ureter
...
The ureteroscope is used to directly visualize the stricture and to pass guide wires to direct the use of laser, balloons, or incisional or electrocautery devices
...
Code 52351 is used to report a diagnostic cystourethroscopy with ureteroscopy and/or pyeloscopy
...
This code is not routinely reported with codes 52341-52346 and 52352-52355, as it describes a diagnostic cystourethroscopy when performed on the same side
...
However, there are instances when a diagnostic cystourethroscopy and a procedure reported using a code from the 52341-52346 or 52352-52355 series are performed on contralateral (opposite) sides of the body
...
In this case, it would be appropriate to report code 52351 separately with modifier 59 appended
...
(Refer to Chapter 8 for further discussion of modifier 59
...
)
Prostate Biopsy Procedures
The standard biopsy is performed under local anesthesia by means of a transrectal approach and involves 6 to 12 cores for sampling of the tissue
...
There are many differences between the saturation prostate needle biopsy (55706) and the standard prostate needle biopsy (55700)
...
Saturation biopsy is performed, for example, in patients having a rising prostate-specific antigen level with previous negative standard biopsy (55700) or a history of prostatic intraepithelial neoplasm
...
The saturation biopsy (55706) must be performed under general anesthesia and uses a transperineal approach using a brachytherapy or stereotactic grid
...
The stereotactic template is positioned over the perineum so that precise and exact coordinates for the biopsy can be taken and documented
...
The urologist transperineally inserts the needle into the prostate
...
Depending on the size of the prostate, approximately 35 to 60 specimens are taken via a stereotactic approach at 5-mm intervals through the template (grid) and removed
...
These specimens are placed in containers, recorded, and then sent to pathology
...
This procedure is meant not to sample but rather to systematically allow collection of samples from the entire prostate gland
...
Prostate Procedures
Codes in the 52450-52700 series are used to report transurethral procedures of the vesical neck and prostate
...
Codes 53850-53852 are also used to report transurethral destruction of prostatic tissue
...
The differences between the two series of codes are reviewed below
...
Code 52601 is used to report procedures commonly referred to as TURP (transurethral resection of the prostate)
...
This procedure uses electrical current to heat a wire loop on a resectoscope that slices through urethral or prostatic tissue like a knife
...
Two settings exist to regulate the current
...
The high-voltage current is used to cut the tissue and the low-voltage current to coagulate the bleeding
...
As indicated in the code descriptor, when code 52601 is reported, vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included, when performed, and not reported separately
...
This code describes a complete TURP
...
However, code 52601 is used for the first and second stages of a TURP
...
The second stage of the TURP is reported using code 52601 with the modifier 58 appended
...
(See Figure 4-56
...
)

FIGURE 4-56
Transurethral Electrosurgical Resection of Prostate, Complete
Code 52630 is used to report the resection of residual or regrowth of obstructive tissue after the initial procedure
Code 52640 is used to report the transurethral resection of postoperative bladder neck contracture
...
CODING TIP For resection of residual prostate tissue performed within the postoperative period of a related procedure performed by the same physician or other health care professional, modifier 78 is appended
...
Code 52647 is used to report laser coagulation of the prostate
...
This code is used to report laser procedures that primarily heat the prostate and require sloughing for the treatment to be complete
...
This code should be used even if an incision or small amount of vaporization is done in combination with the coagulation
...
In this case, it is not appropriate to separately report code 52648 for the small amount of vaporization performed
...
Code 52648 is used to report laser vaporization with or without TURP
...
Vaporization is usually accomplished by moving a laser tip across the surface of the prostate, causing immediate vaporization of tissue and an end result that looks like a cavity (similar to the effect of a TURP)
...
This code should also be used to report the photoselective vaporization of the prostate
...
Another technique for laser treatment of benign prostatic hypertrophy involves placing the laser fiber within the prostatic substance with tissue destruction and delayed cavitation (eg, using an interstitial laser ablation system)
...
Although this technique might appear to be most appropriately reported with code 52648, in fact, it should be reported with code 52647, as the tissue undergoes coagulative necrosis and not immediate vaporization and cavitation
...
Code 52649 is used to report laser enucleation with morcellation of the prostate using a highpower laser source
...
It is performed on a small subset of patients requiring prostate surgery due to the enlarged size of the prostate
...
A laser fiber is used to undermine and dissect away large pieces of prostate tissue that migrate into the bladder
...
the tissue is then cut into small pieces with a morcellator and subsequently extracted at the end of the procedure
...
CPT codes 52000, 52276, 52281, 52601, 52647, 52648, 53020, and 55250 are not reported in addition to code 52649
...
Code 53850 describes transurethral microwave thermotherapy, which is the selective destruction of prostate cells by therapeutic levels of heating
...
Transurethral microwave thermotherapy is a process of delivering sufficient microwave heating to destroy prostatic tissue without causing unnecessary damage to surrounding structures
...
The technique combines the principles of microwave radiation heating and conductive cooling to destroy tissue deep within the prostate while preserving surrounding structures such as the bladder neck, urethral mucosa, and distal sphincter
...
Code 53852 is used to report transurethral destruction by radiofrequency thermotherapy where low-power radiofrequency energy is used to cause tissue ablation and coagulation of prostate tissue
...
Insulated needles are pierced through the prostatic urethra to deliver radiofrequency energy directly into the prostate while the insulation on the needles protects the urethra
...
This procedure creates areas of necrosis within the prostate while preserving the urethral tissue
...
The related code defines the procedure by the energy source used to avoid the inclusion of proprietary procedures (eg, "the TUNA System") in the CPT nomenclature
...
Cryosurgical ablation of the prostate is a procedure that is an alternative to radical prostatectomy or radiation therapy in the treatment of prostate cancer
...
Code 55873 describes this procedure, which uses a cryosurgical probe to destroy diseased tissue by freezing
...
The cryosurgical probes are placed through the perineum into the prostate with the use of ultrasonic guidance imaging
...
The ultrasound probe is placed in the rectum
...
Real-time images from the ultrasound are used to place the cryoprobes and to monitor the treatment
...
CODING TIP Ultrasonic guidance is included when code 55873 is reported
...
Radical retropubic surgical prostectomy, including nerve sparing, can be performed laparoscopically (55866) or open (55840)
...
When performed laparoscopically, code 55866 includes robotic assistance, when performed
...
If a laparoscopic lymphadenectomy is performed, code(s) 38570-38589 are reported with modifier 51 appended
...
Radiation Treatment
Code 55875 is used to report transperineal placement of needles or catheters into the prostate for interstitial radioelement application, with or without cytoscopy
...
For fluoroscopic guidance report 77002 or for ultrasonic guidance report 76965 in addition to 55875
...
For interstitial radioelement application, the radiotherapist reports 77776-77787
...
Code 55876 describes placement, by needle or any approach, of interstitial device(s) in the prostate for radiation therapy guidance
...
The supply of the device is reported separately
...
This may be done with the aid of fiducial markers to improve the accuracy for seed migration and a reduction in organ deformity or with dosimeter for safe dose escalation with external beam radiation therapy
...
This therapeutic procedure is for men with malignant neoplasms of the prostate
...
Radiologic image guidance can be performed via several modalities in conjunction with 55876
...
Depending on modality, report RS&I with codes 76942 (ultrasonic), 77002 (fluoroscopic), 77012 (CT), or 77021 (MRI)
...
PRINCIPLES OF CPT CODING
BOOK III COMPLETE
...