How To Use CPT Code 0499T

CPT 0499T describes a specific medical procedure involving cystourethroscopy, mechanical dilation, and therapeutic drug delivery for the treatment of urethral stricture or stenosis. This article will provide a comprehensive overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0499T?

CPT 0499T is a code used to describe a medical procedure that involves cystourethroscopy, mechanical dilation, and therapeutic drug delivery for the treatment of urethral stricture or stenosis. This procedure is performed by a healthcare provider to dilate the narrowed urethra and deliver therapeutic drugs, such as steroids, to promote healing and prevent scarring or recurrence of the stricture.

2. Official Description

The official description of CPT code 0499T is: ‘Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed.’ It is important to note that this code should not be reported in conjunction with codes 52281 and 52283.

3. Procedure

1. The healthcare provider begins by administering adequate anesthesia to the patient.
2. A well-lubricated cystourethroscope is inserted through the urethral meatus and into the urethra.
3. Using instruments passed through the scope, the provider calibrates and dilates the urethral stricture or stenosis.
4. The catheter is slowly guided up into the bladder, allowing the provider to examine the bladder using a camera attached to the cystoscope.
5. Sterile saline water may be injected into the bladder to improve visibility.
6. Before completely removing the scope, the provider instills therapeutic drugs, such as steroids, into the urethra.
7. Fluoroscopy may be used for imaging guidance during the procedure.

4. Qualifying circumstances

CPT code 0499T is used for patients with urethral stricture or stenosis who require cystourethroscopy, mechanical dilation, and therapeutic drug delivery. It is important to note that this code should not be reported with codes 52281 and 52283.

5. When to use CPT code 0499T

CPT code 0499T should be used when a healthcare provider performs cystourethroscopy, mechanical dilation, and therapeutic drug delivery for the treatment of urethral stricture or stenosis. It is important to ensure that the procedure includes fluoroscopy, if performed.

6. Documentation requirements

To support a claim for CPT code 0499T, the healthcare provider must document the following information:

• Patient’s diagnosis of urethral stricture or stenosis
• Details of the procedure performed, including cystourethroscopy, mechanical dilation, and therapeutic drug delivery
• Documentation of the use of fluoroscopy, if applicable
• Any additional relevant information or findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 0499T, it is important to ensure that the procedure includes cystourethroscopy, mechanical dilation, and therapeutic drug delivery for urethral stricture or stenosis. This code should not be reported in conjunction with codes 52281 and 52283. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 0499T was added to the Current Procedural Terminology system on January 1, 2018. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs cystourethroscopy, mechanical dilation, and therapeutic drug delivery for a patient with urethral stricture, including the use of fluoroscopy.
2. During the procedure, the provider dilates the narrowed urethra and delivers therapeutic drugs to a patient with urethral stenosis, ensuring proper documentation of the procedure and the use of fluoroscopy.
3. A healthcare provider performs cystourethroscopy, mechanical dilation, and therapeutic drug delivery for a patient with recurrent urethral stricture, documenting the details of the procedure and any additional findings.
4. Using fluoroscopy for imaging guidance, a provider performs cystourethroscopy, mechanical dilation, and therapeutic drug delivery for a patient with urethral stenosis, ensuring accurate documentation for billing purposes.
5. A healthcare provider performs cystourethroscopy, mechanical dilation, and therapeutic drug delivery for a patient with urethral stricture, following all documentation requirements and billing guidelines.