How To Use CPT Code 51045

CPT 51045 describes a procedure in which a provider makes an incision into the urinary bladder to insert a stent or catheter into the ureter. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51045?

CPT 51045 is a code used to describe a surgical procedure in which a provider makes an incision into the urinary bladder to insert a stent or catheter into the ureter. This procedure is performed to treat a stricture or blockage in the ureter, allowing for the normal flow of urine from the ureter to the bladder.

2. Official Description

The official description of CPT code 51045 is: ‘Cystotomy, with insertion of ureteral catheter or stent (separate procedure).’ This code indicates that the provider is making an incision into the bladder and inserting a catheter or stent into the ureter to address a stricture or blockage.

3. Procedure

1. When performing CPT 51045, the provider begins by preparing and anesthetizing the patient.
2. An incision is made in the skin of the abdomen overlying the urinary bladder.
3. The provider then dissects through the subcutaneous tissue or just under the skin and muscles to access the bladder.
4. The bladder is checked by inserting a syringe and draining out the urine.
5. An incision is made in the urinary bladder to create access for the catheter or stent.
6. The provider places the catheter or stent in the bladder and passes it through the ureter to facilitate normal urine flow.
7. If necessary, a drainage tube may be inserted before suturing the bladder incision.
8. The provider then closes the abdominal wound by suturing the layers of tissue together.

4. Qualifying circumstances

CPT 51045 is performed when a patient has a stricture or blockage in the ureter that requires intervention. The procedure is typically performed by a qualified healthcare provider who is experienced in urological surgeries. The patient must meet the criteria for the procedure, and the provider must determine that the insertion of a catheter or stent is necessary to address the condition.

5. When to use CPT code 51045

CPT code 51045 should be used when a provider performs a cystotomy and inserts a ureteral catheter or stent as a separate procedure. This code should not be reported if the procedure is performed in an anatomically related region through the same skin incision. If CPT 51045 is performed with an unrelated procedure, modifier 59, Distinct Procedural Service, may need to be appended to the code.

6. Documentation requirements

To support a claim for CPT 51045, the provider must document the following information:

• Patient’s diagnosis indicating the need for the procedure
• Details of the procedure performed, including the insertion of the catheter or stent
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed in conjunction with CPT 51045
• Any complications or unexpected findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 51045, ensure that the procedure is performed as a separate procedure and not in an anatomically related region through the same skin incision. If the procedure is performed with an unrelated procedure, modifier 59 may need to be appended to the code. It is important to follow the specific billing guidelines provided by the payer to ensure accurate reimbursement.

8. Historical information

CPT 51045 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 a cystotomy and inserting a ureteral stent to address a ureteral stricture in a patient.
2. A surgeon making an incision into the bladder and inserting a ureteral catheter to treat a blockage in the ureter.
3. A urologist performing a cystotomy and inserting a ureteral stent to address a ureteral stone causing obstruction.
4. A urologist making an incision into the bladder and inserting a ureteral catheter to facilitate urine flow in a patient with a ureteral stricture.
5. A surgeon performing a cystotomy and inserting a ureteral stent to address a ureteral tumor causing blockage.
6. A urologist making an incision into the bladder and inserting a ureteral catheter to treat a ureteral stricture in a patient.
7. A surgeon performing a cystotomy and inserting a ureteral stent to address a ureteral injury.
8. A urologist making an incision into the bladder and inserting a ureteral catheter to treat a ureteral stricture in a patient.
9. A surgeon performing a cystotomy and inserting a ureteral stent to address a ureteral stricture in a patient.
10. A urologist making an incision into the bladder and inserting a ureteral catheter to treat a ureteral stricture in a patient.