How To Use CPT Code 51040

CPT 51040 describes a procedure known as cystostomy, cystotomy with drainage. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51040?

CPT 51040 is used to describe a surgical procedure called cystostomy, cystotomy with drainage. This procedure involves creating a connection between the urinary bladder and the skin to allow for the drainage of urine in individuals with obstruction of normal urinary flow. It is typically performed under general anesthesia, and a small incision is made over the lower abdominal skin to access the bladder. The muscles, fat layer, and fascia are cut to reach the bladder, and a small incision is made in the bladder. A catheter is then inserted into the bladder to act as a drainage tube, and it is directed to the lower abdominal skin from the bladder and placed outside the skin, creating an opening between the bladder and the abdominal skin.

2. Official Description

The official description of CPT code 51040 is: ‘Cystostomy, cystotomy with drainage.’

3. Procedure

1. After the application of general anesthesia, a small incision is made over the lower abdominal skin to access the bladder.
2. All the muscles, fat layer, and fascia are cut to reach the bladder.
3. A small incision (cystotomy) is made in the bladder.
4. A catheter is passed into the bladder, which acts as a drainage tube.
5. The successful passage of the catheter tube can be confirmed under fluoroscopy.
6. The catheter tube is directed to the lower abdominal skin from the bladder and ultimately placed outside the skin, creating an opening (cystostomy) between the bladder and the abdominal skin.
7. The catheter is fixed either by balloon inflation or by sutures.

4. Qualifying circumstances

CPT 51040 is performed on individuals with obstruction of normal urinary flow, requiring the creation of a connection between the urinary bladder and the skin for urine drainage. This procedure is typically performed by a urologist and may be done under general anesthesia. The specific circumstances and patient conditions that warrant the use of CPT 51040 should be determined by the urologist based on the individual patient’s needs.

5. When to use CPT code 51040

CPT code 51040 should be used when a urologist performs the cystostomy, cystotomy with drainage procedure to create a connection between the urinary bladder and the skin for urine drainage. It is important to ensure that the procedure meets the specific requirements outlined in the official description of CPT code 51040.

6. Documentation requirements

To support a claim for CPT code 51040, the urologist must document the following information:

• Patient’s diagnosis and the need for cystostomy, cystotomy with drainage
• Details of the procedure, including the specific steps performed
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the urologist performing the procedure

7. Billing guidelines

When billing for CPT code 51040, ensure that the procedure meets the specific requirements outlined in the official description. It is important to accurately document and code the procedure to ensure proper reimbursement. Additionally, consider any applicable modifiers or additional codes that may be necessary to accurately represent the services provided.

8. Historical information

CPT code 51040 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A urologist performing cystostomy, cystotomy with drainage for a patient with urinary obstruction.
2. A urologist creating a connection between the urinary bladder and the skin to allow for urine drainage in a patient with bladder dysfunction.
3. A urologist performing cystostomy, cystotomy with drainage as part of the treatment for a patient with bladder cancer.
4. A urologist performing cystostomy, cystotomy with drainage for a patient with urinary retention.
5. A urologist creating a connection between the urinary bladder and the skin to allow for urine drainage in a patient with neurogenic bladder.
6. A urologist performing cystostomy, cystotomy with drainage for a patient with bladder stones.
7. A urologist creating a connection between the urinary bladder and the skin to allow for urine drainage in a patient with urethral stricture.
8. A urologist performing cystostomy, cystotomy with drainage for a patient with urinary incontinence.
9. A urologist creating a connection between the urinary bladder and the skin to allow for urine drainage in a patient with bladder outlet obstruction.
10. A urologist performing cystostomy, cystotomy with drainage for a patient with recurrent urinary tract infections.